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MERS-CoVGuidelinesforHealthcareProfessionals-May2018-v5.11.pdf
MIDDLE EAST RESPIRATORY SYNDROME CORONAVIRUS; GUIDELINES FOR HEALTHCARE PROFESSIONALS
VERSION 5.1
MAY 21, 2018
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1. TABLE OF CONTENTS
1. ACKNOWLEDGMENT ............................................................................................................ 2
2. INTRODUCTION ................................................................................................................... 3
3. OBJECTIVES ......................................................................................................................... 3
4. CASE DEFINITION ................................................................................................................. 4
4.1 SUSPECTED CASE 4
4.2 CONFIRMED CASE 4
5. INFECTION PREVENTION AND CONTROL ............................................................................... 5
5.1 ADMINISTRATIVE INTERVENTIONS 5
5.2 TRANSMISSION PRECAUTIONS 6
5.3 PATIENT PLACEMENT 6
5.4 PATIENT TRANSPORT 7
5.5 PERSONAL PROTECTIVE EQUIPMENT (PPE) FOR HCWS 7
5.6 ENVIRONMENTAL CLEANING AND DISINFECTION 8
5.7 MEDICAL WASTE 10
5.8 TEXTILES 10
5.9 INFECTION PREVENTION AND CONTROL PRECAUTIONS FOR AEROSOL-GENERATING PROCEDURES 10
5.10 FIT TEST AND SEAL CHECK 11
5.11 MANAGEMENT OF EXPOSURE TO MERS-COV IN HEALTHCARE FACILITIES 12
5.12 OUTBREAK MANAGEMENT 14
5.13 PATIENT TRANSPORTATION AND PREHOSPITAL EMERGENCY MEDICAL SERVICES 14
5.14 DURATION OF ISOLATION PRECAUTIONS FOR MERS-COV INFECTION 15
6. PUBLIC HEALTH CONSIDERATIONS ...................................................................................... 15
6.1 SURVEILLANCE AND REPORTING 15
6.2 HOUSEHOLD AND COMMUNITY CONTACTS MANAGEMENT 16
6.3 HOME ISOLATION GUIDANCE 17
6.4 HUMAN ANIMAL INTERFACE 18
7. LABORATORY DIAGNOSIS OF MERS-COV ............................................................................. 19
8. OTHER CONSIDERATIONS ................................................................................................... 20
8.1 GENERAL OUTLINES OF MANAGEMENT 20
8.2 EXTRA CORPOREAL MEMBRANE OXYGENATION (ECMO) 20
8.3 MANAGING BODIES OF DECEASED MERS-COV PATIENTS 21
9. REFERENCES ...................................................................................................................... 22
2. APPENDICES ...................................................................................................................... 23
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1. ACKNOWLEDGMENT
The MERS workshop was hosted by the General Directorate of Infectious Diseases
Control and supported by Assistant Agency for Preventive Health.
We are grateful to all those participants who shared their experience and insight at the
MERS workshop. In alphabetical order: Abdulaziz Alenzy, Abdulaziz Sawan, Abdulhakeem
Althaqafi Abdulhameed Kashkary, Abdullah Alzahrani, Abdullah Asiri, Abdullah Khafagy,
Abuzaid Abdalla, Adel Alothman, Adil Alenezi, Adil Almuhsen, Ahmed Zein, Ahmed Alammar,
Ahmed Alhakwai, Ahmed Elgozoli, Ali Alsomily, Ali Afifi, Ali Akoud, Ali Aldoweriej, Ali
Alhaddad, Ali Alshehri, Ali Younis, Aref Alamri, Asmaa Altamimi, Ayed Asiri, Bandar AlAhmadi,
Eihab Alaagib, Faten bin Saif, Fawaz Alrasheedi, Fhad Alzhrani, Hail Alabdely, Hamid Elsheikh,
Hani Jokhdar, Hasan Alotaibi, Hassan Bahidan, Hatim Makhdoum, Hussain Lulu, Hussein
Hussein, John Watson, Khalid Alenazi, Maha Alawi, Mahgoub Ali, Malik Peiris, Maria Van
Kerkhove, Mohamed Awad, Mohamed Okasha, Mohammed Moustafa, Mohammed Alsayer,
Mona Aref, Moqbil Alhedaithy, Moteb AlSaedi, Moustafa Bahkali, Mutaz Mohammed,
Nagham Abdulrahman, Nasreldin Ismail, Nasser Abutaleb, Omar Bin Khamis, Osama Waheed,
Osamah Alhayani, Osman Hamedelneil, Osman Hashim, Raheela Hussein, Rahma Eltigani,
Rather Salem, Saeed Alqahtani, Saleh Alzaid, Samar Bereagesh, Sameera Aljohani, Sami
Almudarra, Samy Kasem, Sana Alshaikh, Sara Eltigani, Shaihana Almatrrouk, Shamsudeen
Fagbo, Sultana ALajmi, Taghreed Alaifan, Tarik AlAzraqi, Till Elhassan, Yaseen Arabi, Ziad bin
Saad.
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2. INTRODUCTION
Middle East Respiratory Syndrome (MERS) is a viral respiratory disease caused by a novel
coronavirus (Middle East Respiratory Syndrome Coronavirus, or MERS-CoV) that was first
identified in Saudi Arabia in 2012.
Typical MERS-CoV symptoms include fever, cough and shortness of breath. Pneumonia is
common, but not always present. Approximately 35% of reported patients with MERS-CoV
have died.
Although some of human cases of MERS-CoV have been attributed to human-to-human
infections in health care settings, current scientific evidence indicates that dromedary
camels are a major reservoir host for MERS-CoV and an animal source of MERS-CoV infection
in humans.
This is the fifth edition (updated May 2018) of the national MERS-CoV guidelines. A large
group of national and international experts in epidemiology, infectious diseases, infection
control, intensive care, laboratory, veterinary medicine and public health were hosted by
Saudi Ministry of Health (MOH) to review current knowledge and update the guidelines.
3. OBJECTIVES
This document provides guidelines on managing MERS-CoV infection based on the best
available scientific evidence and broad consensus through the following:
● Provide guidance on MERS-CoV surveillance activities in the healthcare setting and
in the community.
● Provide guidance on the infection control precautions for suspected and confirmed
MERS-CoV cases.
● Standardize the clinical management of MERS-CoV patients.
● Provide guidance for rational use of resources including laboratory testing.
● To act as focus for quality control, including audit.
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4. CASE DEFINITION
4.1 SUSPECTED CASE1
Age Clinical Presentation Epidemiologic Link
Adults I. Severe pneumonia (severity score ≥3 points) (Appendix A) or ARDS (based on clinical or radiological evidence)
Not required
Adults2 II. Unexplained deterioration3 of a chronic condition of patients with congestive heart failure or chronic kidney disease on hemodialysis
Not required
Children and adults
III. Acute febrile illness (T ≥380 C) with/without respiratory symptoms OR
IV. Gastrointestinal symptoms (diarrhea or vomiting), AND leukopenia (WBC≤3.5x109 /L) or thrombocytopenia (platelets < 150x109/L)
Within 14 days before symptom onset:
1. Exposure 4 to a confirmed case of MERS-CoV infection OR
2. Visit to a healthcare facility where MERS-CoV patients(s) has recently (within 2 weeks) been identified/treated OR
3. Contact with dromedary camels5 or consumption of camel products (e.g. raw meat, unpasteurized milk, urine)
4.2 CONFIRMED CASE
A Confirmed case is defined as a suspected case with laboratory confirmation of MERS-CoV infection.
1 All suspected cases should have samples collected for MERS-CoV testing (nasopharyngeal swabs or sputum, and when intubated, lower respiratory secretions)
2 Adult is defined as > 14 years old 3 Chronic renal failure and congestive heart failure patients may exhibit fever and presence of fluid overload may mask the radiological features of pneumonia 4 Exposure is defined as a contact within 1.5 meters with a confirmed MERS-CoV patient. 5 Exposure to camels include:
o Direct physical contact with camels or their surroundings (milking and handling excreta are especially risky), drinking raw camel milk or other
unpasteurized products derived from camel milk, and handling raw camel meat.
o Indirect contact include casual contact with camel places like visiting camel market or farms without direct physical contact with camels, living with a
household member who had direct contact with camels.
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5. INFECTION PREVENTION AND CONTROL
5.1 ADMINISTRATIVE INTERVENTIONS
To prevent the transmission of respiratory infections in the healthcare settings,
including MERS-CoV and influenza, the following infection control administrative
measures should be incorporated into infection control practices and implemented:
● Triage for patients with Acute Respiratory Illness (ARI):
o Visual triage should be used for early identification of all patients with ARI in
the Emergency Room and dialysis units.
o Visual triage station should be placed at the entry point of the healthcare
facility (i.e. emergency room entrance, dialysis unit entrance) or other
designated areas and attended by a trained nurse or nurse assistant.
o All patients attending hemodialysis units and all emergency room attendees
(except those with immediately life-threatening conditions) must be triaged
at the entrance using predefined scoring (Appendix B).
o Identified ARI patients should be asked to perform hand hygiene and wear a
surgical mask. They should be isolated and evaluated immediately in an area
separate from other patients, ideally a separate room
● Dedicate a waiting area for the ARI patients with spatial separation of at least 1.2
meter between each ARI patient and others.
● Post visual alerts (in appropriate languages) at the entrance of healthcare facilities
(e.g. emergency rooms and clinics). Messages in the visual alerts include the
following:
o Cover your mouth and nose with a tissue when coughing or sneezing.
o Dispose of the tissue in the nearest waste receptacle immediately after use.
o Perform hand hygiene (e.g. hand washing with non-antimicrobial soap and
water, alcohol-based hand sanitizer, or antiseptic hand wash) after having
contact with respiratory secretions and contaminated objects or materials.
● Prevent overcrowding in clinical areas to reduce the risk of transmission between
patients and to staff.
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o The distance that should be maintained between patients` beds are:
- Minimum of 1.2 meters in General words, Hemodialysis units and
Emergency units.
- Minimum of 2.4 meters in Critical care units.
5.2 TRANSMISSION PRECAUTIONS
MERS-CoV is believed to spread between humans mainly through contact and
respiratory droplets. However, transmission through small particle droplet nuclei
(aerosols) may occur. Environmental contamination during outbreaks in healthcare
facilities can be extensive and might contributes to amplifying outbreaks, if adequate
disinfection procedures are not followed.
● For patients with suspected, or confirmed MERS-CoV infection who are NOT
CRITICALLY ILL, Standard, Contact, and Droplet precautions are recommended.
● For patients who are CRITICALLY ILL, Standard, Contact, and Airborne precautions
are recommended due to the high likelihood of requiring aerosol-generating
procedures.
5.3 PATIENT PLACEMENT
Every healthcare facility should have the capacity to care for patients with transmissible
infections including airborne infections. However, the availability of single rooms and
negative pressure rooms are a challenge in most facilities. The infection control teams
should take the lead in managing isolation rooms.
● Patients with suspected or confirmed MERS-CoV infection who are not critically ill
should be placed in single patient rooms in an area that is clearly segregated from
other patient-care areas. A portable HEPA filter could be used and placed according
to the manufacturer recommendations.
● Critically ill patients with suspected or confirmed MERS-CoV infection should be
placed in Airborne Infection Isolation Rooms (Negative Pressure Rooms), if available.
When negative pressure rooms are not available, the patients should be placed in
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adequately ventilated private rooms with a portable HEPA filter and is placed
according to the manufacturer recommendations.
When single rooms are not available, suspected or confirmed MERS-CoV patients
should be placed with other patients of the same diagnosis (cohorting). If this is not
possible, place patient beds at least 1.2 meters apart.
5.4 PATIENT TRANSPORT
Avoid the movement and transport of patients out of the isolation room or area unless
medically necessary. The use of designated portable X-ray, ultrasound, echocardiogram
and other important diagnostic machines is recommended when possible.
If transport is unavoidable, the following should be observed:
● Patients should wear a surgical mask during movement to contain secretions.
● Use routes of transport that minimize exposures of staff, other patients, and visitors.
● Notify the receiving area of the patient's diagnosis and necessary precautions as
soon as possible before the patient's arrival.
● Ensure that healthcare workers (HCWs) who are transporting patients wear
appropriate PPE and perform hand hygiene afterward.
5.5 PERSONAL PROTECTIVE EQUIPMENT (PPE) FOR HCWS
The following PPE should be worn by HCWs upon entry into patient rooms or care areas
in the respected order:
● Gowns (clean, non-sterile, long-sleeved disposable gown).
● Surgical mask (or N95 when airborne precautions are applied)
● Eye protection (goggles or face shield).
● Gloves.
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For patients on airborne precautions, any person entering the patient's room should
wear a fit-tested N95 mask instead of a surgical mask. For those who failed the fit
testing of N95 masks (e.g. those with beards), an alternative respirator, such as a
powered air-purifying respirator (PAPR), should be used.
● Upon exit from the patient room or care area, PPEs should be removed and
discarded.
● Except for N95 masks, remove PPE at the doorway or in the anteroom. Remove N95
mask after leaving the patient room and closing the door.
● Remove PPEs in the following sequence: 1. Gloves, 2. Goggles or face shield, 3.
Gown and 4. Mask or respirator.
● The following also should be noted:
o The outside of gloves, masks, goggles and face shield are contaminated.
o Never wear a surgical mask under the N95 mask as this prevents proper
fitting and sealing of the N95 mask thus decreasing its efficacy.
o For female staff who wear veils, the N95 mask should always be placed
directly on the face behind the veil and not over the veil. In this instance, a
face-shield should also be used along with the mask to protect the veil from
droplet sprays.
o Whenever possible, use either disposable equipment or dedicated
equipment (e.g. stethoscopes, blood pressure cuffs and thermometers).
5.6 ENVIRONMENTAL CLEANING AND DISINFECTION
Recent data suggested that the environment in health care facilities used for MERS-CoV
patients is widely contaminated. Thorough environmental cleaning and disinfection are
critical.
● Consider designating specific, well-trained housekeeping personnel for cleaning
and disinfecting of MERS-CoV patient rooms/units.
● Define the scope of cleaning that will be conducted each day; identify who will be
responsible for cleaning and disinfecting the surfaces of patient-care equipment
(e.g. IV pumps, ventilators, monitors, etc.).
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● Consider using a checklist to promote accountability for cleaning responsibilities.
● Housekeeping personnel should wear PPE as described above. Housekeeping staff
should be trained by the infection control team about MERS-CoV, in proper
procedures for PPE use, including removal of PPE, and the importance of hand
hygiene.
● Keep cleaning supplies outside the patient room (e.g. in an anteroom or storage
area).
● Keep areas around the patient free of unnecessary supplies and equipment to
facilitate daily cleaning.
● Use MOH-approved disinfectants (see the GCC Infection Prevention and Control
Manual, 3rd edition). Follow manufacturer's recommendations for use-dilution (i.e.
concentration), contact time, and care in handling.
● Clean and disinfect MERS-CoV patients' rooms at least daily and more often when
visible soiling/contamination occurs.
● Give special attention to frequently touched surfaces (e.g. bedrails, bedside and
over-bed tables, TV control, call button, telephone, lavatory surfaces including
safety/pull-up bars, door knobs, commodes, ventilator and monitor surfaces) in
addition to floors and other horizontal surfaces.
● Wipe external surfaces of portable equipment for performing x-rays and other
procedures in the patient's room with a MOH-approved disinfectant upon removal
from the patient's room.
● After an aerosol-generating procedure (e.g. intubation), clean and disinfect
horizontal surfaces around the patient. Clean and disinfect as soon as possible after
the procedure.
● Clean and disinfect spills of blood and body fluids by current recommendations for
spill management outlined in the GCC Infection Prevention and Control Manual, 3rd
edition.
● Cleaning and disinfection after MERS-CoV patient discharge or transfer:
o Follow standard procedures for terminal cleaning of an isolation room. (See
the GCC Infection Prevention and Control Manual, 3rd edition)
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o Clean and disinfect all surfaces that were in contact with the patient or may
have become contaminated during patient care including items such as
blood pressure cuffs, pulse oximeters, stethoscopes, etc.
o Wipe down mattresses and headboards with an MOH-approved disinfectant.
o Privacy curtains should be removed, placed in a bag in the room and then
transported to be laundered.
o No special treatment is necessary for window curtains, ceilings, and walls
unless there is evidence of visible soil.
o Use hydrogen peroxide vapor or UVC machines for disinfection of the room
as mandatory part of the terminal cleaning process.
o If all the procedures mentioned above are followed, then the patient room
can be used immediately for another patient after terminal cleaning.
5.7 MEDICAL WASTE
Housekeeping staff must wear disposable gloves and perform hand hygiene after
removal of gloves when handling waste.
Collection and disposal of MERS-CoV contaminated medical waste should follow the
GCC Infection Prevention and Control Manual, 3rd edition.
5.8 TEXTILES
General concepts when dealing with linen in MERS-CoV patient’s room are outlined in
the GCC Infection Prevention and Control Manual, 3rd edition.
5.9 INFECTION PREVENTION AND CONTROL PRECAUTIONS FOR AEROSOL-GENERATING
PROCEDURES
An aerosol-generating procedure (AGP) is defined as any medical procedure that can
induce the production of aerosols of various sizes, including small (< 5 microns)
particles.
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AGPs includes bronchoscopy, sputum induction, intubation and extubation,
cardiopulmonary resuscitation, open suctioning of airways, Ambu bagging,
nebulization therapy, high frequency oscillation ventilation and Bilevel Positive Airway
Pressure ventilation- BiPAP (BiPAP is not recommended in MERS-CoV infected patients
because of the high risk of generating infectious aerosols and lack of evidence for
efficacy).
Additional precautions should be observed when performing aerosol- generating
procedures, which may be associated with an increased risk of infection transmission:
● Perform procedures in a negative pressure room.
● Limit the number of persons present in the room to the absolute minimum required
for the patient’s care and support.
● Wear N95 masks: Every healthcare worker should wear a fit-tested seal check N95
mask (or an alternative respirator if fit testing failed).
● Wear eye protection (i.e. goggles or a face shield).
● Wear a clean, non-sterile, long-sleeved gown and gloves (some of procedures
require sterile gloves).
● Wear an impermeable apron for some procedures with expected high fluid volumes
that might penetrate the gown.
● Perform hand hygiene before and after contact with the patient and his or her
surroundings and after PPE removal.
5.10 FIT TEST AND SEAL CHECK
The protection offered by a disposable particulate respirator (e.g.N95) depends on its
tight fitting to the user’s face. Standardized respirator fit testing helps identify the
correct respirator size and shape.
● Healthcare workers are required to have a respirator fit test at least once every 2
years and if weight fluctuates or facial/dental alterations occur.
● A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.
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● Each time a respirator is donned, a seal check must be performed using the
procedures recommended by the manufacturer of the respirator.
● For healthcare workers who have facial hair that comes between the sealing surface
of the facepiece and the face of the wearer a Powered Air Purifying Respirator
(PAPR) should be used instead.
5.11 MANAGEMENT OF EXPOSURE TO MERS-COV IN HEALTHCARE FACILITIES
5.11.1 Healthcare workers exposed to a MERS-CoV case
Healthcare facilities should identify and trace all health care workers who had
protected (proper use of PPE) or unprotected (without wearing PPE or PPE used
improperly) exposure to patients with suspected, or confirmed MERS-CoV infection.
The decision to permit a healthcare worker to resume his/her duties after an exposure
to MERS-CoV should be individualized. Infection control team will be ultimately
responsible for taking that decision.
The following are general guidelines but management will depend on the infection
control team risk assessment:
a. Asymptomatic healthcare workers WITH protected exposure OR unprotected low-
risk exposure (more than 1.5 meters of the patient):
o Testing healthcare workers for MERS-CoV is not recommended
o Healthcare workers can continue their duties
o Healthcare workers shall be assessed daily for 14 days post exposure for the
development of symptoms
o Healthcare workers should delay travel until cleared by infection control
team.
o Asymptomatic healthcare workers WITH protected exposure OR
unprotected low-risk exposure are considered CLEAR if they:
- Remain asymptomatic AND
- The observation period is over (14 days post exposure).
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b. Healthcare workers who had unprotected high-risk exposure (within 1.5 meters of
the patient) or have suggestive symptoms regardless of exposure type:
o Healthcare workers shall stop performing their duties immediately.
o Testing (Nasopharyngeal swabs) for MERS-CoV is required (preferably 24hr
or more after the exposure)
o Healthcare workers shall not resume their duties until cleared by infection
control team.
o Healthcare workers should delay travel until cleared by infection control
team.
o Healthcare workers who test positive for MERS-CoV (regardless of the
exposure type); healthcare workers who develop MERS-CoV suggestive
symptoms (regardless of the exposure type) and healthcare workers who had
unprotected high-risk exposure are considered CLEAR if:
- They are asymptomatic for at least 48 hrs AND
- The observation period is over (14 days post exposure) AND
- Had at least one negative RT-PCR for MERS-CoV.
5.11.2 Patients exposed to a MERS-CoV case
Patients can be exposed to MERS-CoV patients prior to diagnosis or due to the failure
of implementing recommended isolation precautions. The following are general
guidelines but management will depend on the infection control team risk assessment:
● Patients sharing the same room (any setting e.g. ward with shared beds, open ICU,
open emergency unit, etc.) with a confirmed case of MERS-CoV for at least 30
minutes:
o Testing (Nasopharyngeal swabs or deep respiratory sample if intubated) for
MERS-CoV is required (preferably 24hr or more after the exposure).
o Patients should be followed daily for symptoms for 14 days after exposure.
o If negative on initial testing, exposed patients should be retested with RT-
PCR if they develop symptoms suggestive of MERS-CoV within the follow up
period.
o Patients discharged during the follow up period must be reported to public
health department to continue monitoring for symptoms.
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5.12 OUTBREAK MANAGEMENT
Healthcare facility outbreak is defined as evidence of one or more secondary
transmissions of MERS-CoV within the healthcare facility.
The investigation of MERS-CoV outbreak is managed by the Infection Prevention Unit
of the hospital, Regional Command and Control Center (RCCC) and Central Command
and Control Center and is discussed in Communicable Diseases Outbreaks in Healthcare
Facilities; Management Guidelines.
Interventions such as media communication, partial or complete closure of hospitals or
units, and activation of surge plan must be coordinated with the central Command and
Control Center.
Contact tracing and testing shall follow approved protocols. Indiscriminate testing
hamper outbreak control efforts and waste valuable resources.
5.13 PATIENT TRANSPORTATION AND PREHOSPITAL EMERGENCY MEDICAL SERVICES
Patients who may have MERS-CoV infection may be safely transported in any
emergency vehicle with the proper precautions.
● Train EMS staff, including drivers, on basic infection control skills with emphasis on
respiratory protection. Like other healthcare workers, respirator fit testing is also
required.
● Minimize the number of people involved in the transport.
● When possible, use vehicles that have a separate driver and patient compartments
and close the door/window between these compartments.
● Use a vehicle equipped with a HEPA filter incorporated into the ventilation unit
especially for transporting patients on mechanical ventilation. If this unit is not
available, set the regular vehicle's ventilation system to the non-circulating mode.
● Transport staff including the driver shall use PPE as described above (Personal
Protective Equipment for Healthcare Workers).
● Place a surgical mask on the patient (if tolerated) and have the patient cover the
mouth/nose with a tissue when coughing.
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● Oxygen delivery with a non-rebreather face mask may be used to provide oxygen
support during transport.
● Coordinate with the receiving facility to receive the patient at the ambulance door
and limit the need for EMS personnel to enter the emergency department.
● Remove and discard PPEs in a medical waste container and follow standard
operating procedures for reprocessing used linen.
● Clean and disinfect the vehicle and reusable patient-care equipment using an MOH-
approved hospital disinfectant. Personnel performing the cleaning should wear a
disposable gown and gloves (a respirator is generally not needed).
● Ensure appropriate follow-up and care of EMS personnel who transport MERS-CoV
patients as recommended for HCWs.
5.14 DURATION OF ISOLATION PRECAUTIONS FOR MERS-COV INFECTION
The infectivity period for MERS-CoV may last as long as virus is being shed. Out of
protocol testing in confirmed MERS-CoV patients is discouraged. For all patients, re-
testing can be done at the end of the first week of confirmation.
In order to discontinue isolation precautions, two negative lower respiratory samples
24 hours apart are required for ventilated patients and one negative respiratory sample
in other patients including home isolated individuals. (Appendix C).
6. PUBLIC HEALTH CONSIDERATIONS
6.1 SURVEILLANCE AND REPORTING
MERS-CoV is a category I reportable infectious disease (within 24 hrs). All healthcare
facilities must report suspected cases through Health Electronic Surveillance Network
(HESN). Results of laboratory testing are also reported through HESN. Failure of
healthcare organizations or healthcare professionals to report reportable infectious
diseases will result in legal actions and may affect licensing and certification.
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6.2 HOUSEHOLD AND COMMUNITY CONTACTS MANAGEMENT
The public health team at the regional health directorate is responsible for listing,
tracing and follow up of household and other contacts of patients with MERS-CoV
infection in the community.
A communication link with a healthcare provider should be established for the duration
of the observation period.
Community and household contacts of MERS-CoV cases are defined as a person who
shared the same enclosed space (e.g. room, office) for frequent or extended periods
with the index case while the index case is symptomatic. Contact tracing assessment
forms must be filled out for all contacts (Appendix D).
Contacts are categorized by the presence or absence of suggestive MERS-CoV
symptoms at the first assessment:
● Contacts without suggestive MERS-CoV symptoms should be listed for follow up
(Appendix D). Screening for MERS-CoV is not generally required. In certain situations,
MERS-CoV screening may be considered:
o If the exposed contact had intense exposure to the MERS-CoV case (e.g. direct
care, sleeping in same room)
o If exposed contact is Immunocompromised (e.g. cancer, organ failure, use of
immunosuppressive medications) or has other chronic underlying conditions
(e.g. diabetes, hypertension)
● Contacts with suggestive MERS-CoV symptoms should be assessed clinically and
referred to a healthcare facility if admission deemed necessary (Appendix D). A
nasopharyngeal swab should be collected by a trained personnel and sent for
MERS-CoV screening.
The observation period of a MERS-CoV community and household contacts is 14 days
after the last exposure. Longer observation may be required if more than one
generation of transmission is identified.
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Contacts who develop symptoms require enhanced monitoring for disease progression.
Health status must be checked by phone and if feasible, by face-to-face visits on a daily
base.
6.3 HOME ISOLATION GUIDANCE
Individuals infected with MERS-CoV who are stable enough can be safely managed at
their homes. The public health team at the regional health directorate should assess
whether the house is suitable for home isolation.
A suitable home setting entails:
● A dedicated well ventilated bedroom for the infected individual
● An educated healthy and rapidly accessible caregiver
● A reliable communication tool (e.g. mobile phone)
Recommendations to Individuals infected and the caregivers include:
● The infected individual is instructed to limit contact with others as much as possible
and to strictly adhere to respiratory etiquette and hand hygiene.
● The household members should stay in a different room or, if not possible, maintain
a distance of at least one meter.
● The household members should wear a medical mask when in the same room
(within one meter) with the infected individual. Masks should not be touched or
handled during use. If the mask gets wet or dirty with secretions, it must be changed
immediately.
● Caregiver should use disposable gloves when handling the infected individual`s
body secretions and perform hand hygiene after removing gloves.
● Used mask, gloves, tissues and other disposable items should be discarded in a
covered waste bin, and hand hygiene performed after touching these items.
● Touched surfaces in the infected individual’s room should be cleaned daily with
regular household cleaners or a diluted bleach solution (1 part bleach to 99 parts
water). The bathroom and toilet surfaces should be daily with regular household
cleaners or a diluted bleach solution (1 part bleach to 9 parts water).
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● Soiled clothes, bed sheets, and towels of the infected individual should not be
shaken. They can be cleaned using regular laundry soap and water.
6.4 HUMAN ANIMAL INTERFACE
Dromedary camels (Camelus Dromedarius) are the natural reservoir for MERS-CoV.
Camel to human transmission seems to occur with direct or indirect contact with
camels or their surrounding environment.
All community acquired MERS-CoV infections should be investigated for direct or direct
links to camel (Appendix D). The exposure history might not be obvious and deep
inquiries are usually necessary.
Direct or indirect exposure of human MERS-CoV cases to camels are reported to the
field investigation team at the ministry of environment, water and agriculture.
Interventions from the animal health side include:
● Field visit to the presumed exposure site
● If camels are identified at the presumed exposure site, they will be quarantined and
tested for MERS-CoV.
● Sampling testing techniques are detailed in the MEWA manual for field investigation.
● If live virus is detected in a camel herd, the quarantine period will be extended until
the live virus is no longer detected.
As a general precaution, anyone visiting farms, markets, barns, slaughterhouses or
other places where dromedaries are present should practice general hygiene measures,
including regular hand washing after touching animals, avoiding touching eyes, nose or
mouth with hands, and avoiding contact with sick animals. People should also consider
wearing protective gowns and gloves while handling animals.
Slaughterhouses and meat processing plants are required to safely dispose heads and
respiratory organs (trachea and lung) of slaughtered camels.
The consumption of raw or undercooked animal products, including milk and meat
carries a high risk of infection from a variety of organisms that might cause disease in
humans. Animal products processed appropriately through proper cooking or
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pasteurization are safe for consumption but should also be handled with care, to avoid
cross-contamination with uncooked foods or from contaminated environment.
Camel barns, farms and markets must be permanently relocated outside residential
areas. Since 2015, Hajj and Umrah zones are declared camel free areas.
For Approved MERS-CoV Surveillance forms see (Appendix D).
7. LABORATORY DIAGNOSIS OF MERS-COV
Laboratory testing for MERS-CoV is performed to confirm a clinically suspected case and to
screen contacts as per approved protocols.
● Regional MOH and selected non-MOH governmental laboratories are approved to
test for MERS-CoV by using validated commercial Real-time reverse-transcription
polymerase chain reaction (rRT-PCR) assays.
● Laboratory confirmation of MERS-CoV infection requires either a positive rRT-PCR
result for at least two specific genomic targets; region upstream and open reading
frame1a (upE and ORF1a).
● It is strongly advised that lower respiratory specimens such as sputum,
endotracheal aspirate, or bronchoalveolar lavage be used when possible. If patients
do not have signs or symptoms of lower respiratory tract infection or lower tract
specimens are not possible or clinically indicated, nasopharyngeal specimens
should be collected.
● If initial testing of a nasopharyngeal swab is negative in a patient who is strongly
suspected to have a MERS-CoV infection, patients should be retested using a lower
respiratory specimen or, if not possible, repeat a nasopharyngeal specimen.
For guidelines on MERS-CoV Sample collection, packaging and shipping (Appendix E).
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8. OTHER CONSIDERATIONS
8.1 GENERAL OUTLINES OF MANAGEMENT
Suspected or confirmed MERS-CoV patients should be admitted to health-care facilities
only if medically indicated. Clinically stable patients or asymptomatic infections can be
managed at home (see Home isolation guidance below).
Confirmed MERS-CoV cases can potentially be managed at any hospital. However, in
certain occasions, it might be necessary to transfer a confirmed MERS-CoV case to a
higher center in coordination with central command and control center. Indication for
transfer to a MERS-CoV designated hospitals (see Communicable Diseases Outbreaks in
Healthcare Facilities; Management Guidelines) include:
● Inability to comply with infection control requirements as decided by the regional
command and control center (e.g. staffing issues, overcrowding, lack of isolation
rooms).
● Reduce the risk of outbreak during mass gathering (e.g. transfer confirmed cases
outside Hajj zone during the Hajj season).
● Critically ill patients who may require sophisticated potentially lifesaving
interventions (e.g. Extra-Corporeal Membrane Oxygenation).
● MERS-CoV is still a relatively uncommon cause of pneumonia. Therefore, patients
admitted with suspected MERS-CoV pneumonia should be treated as per the
community acquired pneumonia guidelines.
The use of non-invasive ventilation (e.g. Bi-level Positive Airway Pressure- BiPAP) should
be avoided in patients with suspected or confirmed MERS-CoV pneumonia. This
intervention enhances the risk of infection transmission through the aerosol generation
and it lacks evidence of efficacy over endotracheal intubation and mechanical
ventilation.
Meticulous supportive care is paramount to decrease mortality from MERS-CoV
infection.
The use of antivirals for MERS-CoV is not recommended outside clinical trials.
8.2 EXTRA CORPOREAL MEMBRANE OXYGENATION (ECMO)
There is evidence that ECMO may offer survival benefits in some MERS-CoV patients.
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ECMO may be considered in patients with following parameters:
● Age < 60 years with a potentially reversible lung pathology
● Murray score for Acute Lung Injury of 3-4 despite optimal care
● ECMO is relatively contraindicated in some situations, for example:
● Any condition that would limit the benefit of ECMO (such as severe neurologic
injury or advanced malignancy).
● Any contraindication to anticoagulation.
● High FiO₂ requirements (>90) or high-pressure mechanical ventilation (P-plat >30)
for 7 days or more.
● Limited vascular access
● Transfer of a MERS-CoV patient to an ECMO center shall be decided mutually
between referring and accepting physicians.
Patients who meet above conditions and require transfer to an ECMO center may be
considered for ECMO cannulation on-site in the correct clinical setting and then
transferred.
List of centers that provide ECMO services to respiratory failure patients resulting from
MERS-CoV and other etiologies can be accessed on Command and Control Center (CCC)
page on the MOH website (www.moh.gov.sa/ccc).
8.3 MANAGING BODIES OF DECEASED MERS-COV PATIENTS
Although no postmortem transmission of MERS-CoV has ever been documented,
deceased bodies theoretically may pose a risk when handled by untrained personnel.
Body washing of MERS-CoV cases should preferably be done at hospitals. However, it
can be safely performed in public washing facilities attached to mosques provided that
the washers have been trained on relevant infection control precautions including
appropriate use of PPEs.
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9. REFERENCES
1. Zaki AM, van Boheemen S, Bestebroer TM, Osterhaus AD, and Fouchier RA. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med. 2012;367(19):1814-20.
2. Assiri A, McGeer A, Perl TM, Price CS, Al Rabeeah AA, Cummings DA, Alabdullatif ZN, Assad M, Almulhim A, Makhdoom H, et al. Hospital outbreak of Middle East respiratory syndrome coronavirus. N Engl J Med. 2013;369(5):407-16.
3. Oboho IK, Tomczyk SM, Al-Asmari AM, Banjar AA, Al-Mugti H, Aloraini MS, Alkhaldi KZ, Almohammadi EL, Alraddadi BM, Gerber SI, et al. 2014 MERS-CoV outbreak in Jeddah--a link to health care facilities. N Engl J Med. 2015;372(9):846-54.
4. Madani TA, Azhar EI, and Hashem AM. Evidence for camel-to-human transmission of MERS-CoV coronavirus. N Engl J Med. 2014;371(14):1360.
5. Mohd HA, Al-Tawfiq JA, and Memish ZA. Middle East Respiratory Syndrome Coronavirus (MERS-CoV) origin and animal reservoir. Virol J. 2016;13(87.
6. Reusken CB, Farag EA, Haagmans BL, Mohran KA, Godeke GJt, Raj S, Alhajri F, Al-Marri SA, Al-Romaihi HE, Al-Thani M, et al. Occupational Exposure to Dromedaries and Risk for MERS-CoV Infection, Qatar, 2013-2014. Emerg Infect Dis. 2015;21(8):1422-5.
7. Muller MA, Meyer B, Corman VM, Al-Masri M, Turkestani A, Ritz D, Sieberg A, Aldabbagh S, Bosch BJ, Lattwein E, et al. Presence of Middle East respiratory syndrome coronavirus antibodies in Saudi Arabia: a nationwide, cross-sectional, serological study. Lancet Infect Dis. 2015;15(6):629.
8. Azhar EI, El-Kafrawy SA, Farraj SA, Hassan AM, Al-Saeed MS, Hashem AM, and Madani TA. Evidence for camel-to-human transmission of MERS-CoV coronavirus. N Engl J Med. 2014;370(26):2499-505.
9. Memish ZA, Assiri AM, and Al-Tawfiq JA. Middle East respiratory syndrome coronavirus (MERS-CoV) viral shedding in the respiratory tract: an observational analysis with infection control implications. Int J Infect Dis. 2014;29(307-8.
10. Oh MD, Park WB, Choe PG, Choi SJ, Kim JI, Chae J, Park SS, Kim EC, Oh HS, Kim EJ, et al. Viral Load Kinetics of MERS-CoV Coronavirus Infection. N Engl J Med. 2016;375(13):1303-5.
11. Balkhy HH, Alenazi TH, Alshamrani MM, Baffoe-Bonnie H, Arabi Y, Hijazi R, Al-Abdely HM, El-Saed A, Al Johani S, Assiri AM, et al. Description of a Hospital Outbreak of Middle East Respiratory Syndrome in a Large Tertiary Care Hospital in Saudi Arabia. Infect Control Hosp Epidemiol. 2016;37(10):1147-55.
12. Bin SY, Heo JY, Song MS, Lee J, Kim EH, Park SJ, Kwon HI, Kim SM, Kim YI, Si YJ, et al. Environmental Contamination and Viral Shedding in MERS-CoV Patients During MERS-CoV Outbreak in South Korea. Clin Infect Dis. 2016;62(6):755-60.
13. Kim SH, Chang SY, Sung M, Park JH, Bin Kim H, Lee H, Choi JP, Choi WS, and Min JY. Extensive Viable Middle East Respiratory Syndrome (MERS-CoV) Coronavirus Contamination in Air and Surrounding Environment in MERS-CoV Isolation Wards. Clin Infect Dis. 2016;63(3):363-9.
14. Alshahrani, M. S., Sindi, A., Alshamsi, F., Al-Omari, A., El Tahan, M., Alahmadi, B., ... & Abdelzaher, M. (2018). Extracorporeal membrane oxygenation for severe Middle East Respiratory Syndrome. Ann Intensive Care. 2018 Jan 10;8(1):3. doi: 10.1186/s13613-017-0350
15. Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) – Version 2. Centers for Disease Control and prevention (CDC). 9 January 2014. Available at: http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html
16. Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Centers for Disease Control and prevention (CDC). Available at: http://www.cdc.gov/coronavirus/mers/guidelines-lab-biosafety.html
17. Laboratory Testing for Middle East Respiratory Syndrome Coronavirus; Interim guidance (revised). January 2018. Available at: http://www.who.int/csr/disease/coronavirus_infections/mers-laboratory- testing/en/.
18. Laboratory Biosafety Manual - Third Edition. World Health Organization 2004. Available at: http://www.who.int/csr/resources/publications/biosafety/en/Biosafety7.pdf.
19. Guidance on regulations for the Transport of Infectious Substances 2007– 2008. Applicable as from 1 January 2007. Available at: http://www.who.int/csr/resources/publications/biosafety/WHO_CDS_EPR_2007_2cc.pdf.
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2. APPENDICES
Appendix A: Pneumonia Severity Index (PSI) scoring
Appendix B: Visual triage checklist
Appendix C: Algorithm for Managing Suspected MERS-CoV Patients
Appendix D: MERS-CoV Surveillance Forms
o Form 1 : MERS CoV Hospital Based reporting Form o Form 2 : MERS CoV Community Surveillance Form o Form 3 : Line Listing Record for Household and Other Contacts o Form 4 : Line Listing Record for Healthcare Workers Contacts
Appendix E: Guidelines for MERS-CoV Sample Collection, Packaging and Shipping
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APPENDIX A
Severity Scores for Community-Acquired Pneumonia (CURB 65)*
Clinical Factor Points
Confusion 1
Blood urea nitrogen > 19 mg per dL 1
Respiratory rate ≥ 30 breaths per minute 1
Systolic blood pressure < 90 mm Hg OR
Diastolic blood pressure ≤ 60 mm Hg 1
Age ≥ 65 years 1
Total points
* CURB-65 = Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of age and older.
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APPENDIX B
Visual Triage Checklist
Visual Triage Checklist for Acute Respiratory Illness
Date: Time MRN:
Name: ID#: Hospital:
Points (adults)
Pints (children)
Score
A. Clinical symptom/sign
Fever 2 1
Cough (New or worsening) 2 1
Shortness of breath (New or worsening) 2 1
Nausea, vomiting, diarrhea 1 -
Sore throat and/or runny nose 1 -
Chronic renal failure, CAD/heart failure 1 -
B. Risk of exposure to MERS
Exposure to a confirmed MERS case in the last two weeks
3 3
Exposure to camel or products (Direct or indirect*) in the last two weeks
2 2
Visit to a healthcare facility that had MERS case in the last two weeks
1 1
Total Score
* Patient or household
A SCORE ≥ 4, PLACE PATIENT IN AN ISOLATION ROOM AND INFORM MD FOR ASSESSMENT
MERS COV TESTING SHOULD BE DONE ONLY ACCORDING TO CASE DEFINITION
Staff name: _____________________ ID number: __________________
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APPENDIX C
Algorithm for Managing Suspected MERS-CoV Patients
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APPENDIX D
MERS-CoV Surveillance Forms
MERS CoV Hospital Based reporting Form (Form 1) التبليغ لحاالت متالزمة الشرق األوسط التنفسية
)1نموذج رقم ( بالمستشفيات
Part 1. InitialNotification Form (Suspect/Confirmed)
فسية التن التبليغ المبدئي لحالة متالزمة الشرق األوسط: 1الجزء )مؤكدة /مشتبة(
Date of initial notification: _____________________ تاريخ التبليغ :
1.0 Details on facility reported suspect case: 1 .0 المبلغة للحالة: معلومات عن المنشأة الصحية:
1. Hospital Name: 1 .اسم المستشفى :
City: __________________ :المدينة
Province: ____________ :المحافظة
Region: __________________القصيم :المنطقة
2. Name of who completed the form:
اسم من قام بالتبليغ عن . 2 الدكتور عالء محمد عبد العليم : الحالة
3. Phone No.:
Fax:_____________________ :الفاكس
Mobile ______________________ :الجوال
رقم هاتف . 3 :المبلغ
4. Email: 4 . البريد اإللكتروني:
1.1 Case Information 1.1 معلومات عن الحالة :
1. Name (Family) اسم :العائلة
(First, Middle االسم ( :األول واالب
عبد الرحمن حسين
2. Date of Birth (AGE) :
________dd/_________mm/_________yyyy 2 . العمر ( تاريخ الميالد :(
3. Gender: Male ذكر Female ذكر: الجنس . 3 انثى
4. Nationality: 4 . الجنسية:
5. Identification No.: 5 . رقم الهوية:
6. Type of Identification:
ID هوية وطنية
_____________
Iqama إقامة _____________
Passport جواز سفر
__________________
Other: Specify _________________ اخرى
: نوع الهوية. 6
7. Hospital File number ( if applicable):
): إن توفر(الطبي رقم الملف. 7
8. Occupation: Health Care Worker: 8 . في المجال الصحي : العمل:
If No, Specify :
وع إذا كانت اإلجابة بـ ال ، الرجاء تحديد ن _______________________ : العمل
9. Phone No.:
Home: _____________المنزل. ______
Mobile: ______________________ :الجوال
ارقام الهاتف . 9 : للحالة
10. Address:
House No. : _______ رقم المنزل
Street Name :______________________ :اسم الشارع
: عنوان الحالة. 10
District Name: ________ اسم :الحي
City: _________ :المدينة
Province/Region: ___________ :المنطقة/حافظةالم
11. Contact Person (friend, relative):
اسم شخص قريب . 11 :للتواصل
12. Phone No.: Home: __________________ :المنزل
Mobile: الجوا_______________________ :ل
: ارقام الهاتف. 12
1.2 Suspected case 2.1 الخواص اإلكلينيكية للمريض :
1. Date of onset of symptoms
: تاريخ ظهور األعراض. 1
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2. Reason for testing: Health Care Worker عامل صحي
مخالط لحالة :سبب طلب الفحص المخبري . 2
Community contact مخالط مجتمعي
3. Reason for testing (Suspect):
سبب طلب الفحص المخبري . 3 ) :اإلشتباه(
1. Case criteria Fever and community-
acquired Severe pneumonia (severity score ≥3 points)Appendix-A or ARDS (based on clinical or radiological evidence)
2.Case criteria Unexplained deterioration
of a chronic condition of patients with congestive heart failure or chronic kidney disease on hemodialysis
3.Case criteria Acute febrile illness (T ≥380 C) with/without respiratory symptoms
4. Case criteria Gastrointestinal symptoms (diarrhea or vomiting), AND leukopenia (WBC≤3.5x109 /L) or thrombocytopenia (platelets < 150x109/L)
. Infectious disease consultant recommended
. Patient Asymptomatic
1.3 Laboratory MERS CoV testing results 3.1 معلومات الفحص المخبري ونتائجها
Type of specimen collected:
Throat swab
Nasopharyngeal swab
Broncho-alveolar lavage Tracheal aspirate
EDTA
blood Tissue Biopsy sputum Urine other
1 .
Date sample collected تاريخ أخذ العينة:
Date sample sent تاريخ إرسال العينة:
Date result obtained تاريخ ظهور نتيجة الفحص المخبري:
Lab Result: Positive Negative Unclear
Rejected ………………………. حص المخبرينتيجة الف:
Type of specimen collected:
Throat swab
Nasopharyngeal swab
Broncho-alveolar lavage Tracheal aspirate
Serum EDTA
blood Tissue Biopsy Stool Urine
2 .
Date sample collected _dd_/_mm__/_yyyy_ تاريخ أخذ العينة:
Date sample sent _dd_/_mm__/_yyyy_ تاريخ إرسال العينة:
Date result obtained _dd_/_mm__/_yyyy_ فحص المخبريتاريخ ظهور نتيجة ال:
Lab Result: Positive Negative Unclear
Rejected ………………………. نتيجة الفحص المخبري:
Type of specimen collected:
Throat swab
Nasopharyngeal swab
Broncho-alveolar lavage Tracheal aspirate
Serum EDTA
blood Tissue Biopsy Stool Urine
3 .
Date sample collected _dd_/_mm__/_yyyy_ تاريخ أخذ العينة:
Date sample sent _dd_/_mm__/_yyyy_ تاريخ إرسال العينة:
Date result obtained _dd_/_mm__/_yyyy_ تاريخ ظهور نتيجة الفحص المخبري:
Lab Result: Positive Negative Unclear
Rejected ………………………. نتيجة الفحص المخبري:
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Type of specimen collected:
Throat swab
Nasopharyngeal swab
Broncho-alveolar lavage Tracheal aspirate
Serum EDTA
blood Tissue Biopsy Stool Urine
4 .
Date sample collected _dd_/_mm__/_yyyy_ تاريخ أخذ العينة:
Date sample sent _dd_/_mm__/_yyyy_ تاريخ إرسال العينة:
Date result obtained _dd_/_mm__/_yyyy_ تاريخ ظهور نتيجة الفحص المخبري:
Lab Result: Positive Negative Unclear
Rejected ………………………. نتيجة الفحص المخبري:
Type of specimen collected:
Throat swab
Nasopharyngeal swab
Broncho-alveolar lavage Tracheal aspirate
Serum EDTA
blood Tissue Biopsy Stool Urine
5 .
Date sample collected _dd_/_mm__/_yyyy_ تاريخ أخذ العينة:
Date sample sent _dd_/_mm__/_yyyy_ تاريخ إرسال العينة:
Date result obtained _dd_/_mm__/_yyyy_ تاريخ ظهور نتيجة الفحص المخبري:
Lab Result: Positive Negative Unclear
Rejected ………………………. نتيجة الفحص المخبري:
Note for Hospital: Complete the table for all of the samples sent to the laboratory. Add additional page if needed. According to treatment guidelines, if the patient is suspected in hospital, he will remain suspected until symptoms have resolved, irrespective of the negative test results
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Fill this part when the Case Confirmed يستكمل هذا الجزء عند تأكيد تشخيص الحالة
Part 2. Case confirmation الحالة مؤكدة: 2الجزء
2.1 Confirmation details 1.2تفاصيل الحالة المؤكدة :
1. Is the case confirmed with the positive laboratory result.
Yes نعم No هل الحالة تأكدت بالتحليل . 1 ال : المخبري
Note: According to treatment guidelines, if a patient is suspected in the hospital, he/she will remain suspected until symptoms have resolved, irrespective of the negative test results, unless other infectious disease is confirmed.
فى، تستمر إستناداً إلى دليل المعالجة، إذا كان المريض مشتبه بالمستش: مالحظة نظر بهة إلى حين إختفاء األعراض بغض المعاملة الحالة على انها مشت
رض فيما عدا تأكيد التشخيص لم. عن النتائج السلبية للفحص المخبري . مختلف
If the clinical picture makes a MERS-CoV infection probable, please proceed with the following form.
متالزمة بمحتملة بإصابتها إذا كانت الشواهد اإلكلينيكية تدل على أن الحالة
.الشرق األوسط التنفسية، الرجاء إستكمال هذا الجزء
2. How many people live in the same household?
( 12. ) عدد األشخاص الذين يعيشون مع المريض . 2
: بالمنزل
3. Was patient hospitalized when the positive result was obtained?
المريض منوم بالمستشفى عند ظهور النتيجة هل كان . 3 إيجابية ؟ نعم
Yes نعم
Date of admission:…………………………………………………………………….. تاريخ الدخول
4. If hospitalized, what was the initial reason for hospitalization?
؟ما هو السبب الرئيسي للتنويم
Respiratory symptoms أعراض تنفسية
Home conditions considered inappropriate isolationالمنزل غير مناسب للعزل
Other, specify :....................................... غير ذلك، حدد:
5. Which department:
حدد القسم المنوم به المريض
ICUالعناية المركزة
Ward, specify : :............................................... حدد القسم
6. If hospitalized, Isolated?
Yes نعم No المريض بغرفة العزل؟ هل. 6 ال
No ال
7.If not hospitalized, inform the Department of Public Health and send copy of the Hospital based form(Part 1 لand Part2)
إرسال نسخة من عالمحافظة م/إذا المريض لم يكن منوماُ بالمستشفى، يجب إبالغ إدارة الصحة العامة بالمنطقة. 7 كامل النموذج
Date the case was transferred to Public Healthcare Department
/تاريخ إبالغ إدارة الصحة العامة بالمنطقة
المحافظة
8. If the patient is not hospitalized to your facility at the time the case is confirmed, please specify the status of the patient:
ة، في حال لم يكن المريض منوم بالمستشفى عند تأكيد الحال. 8 : الرجاء تحديد وضع المريض
Isolated at home
تم عزله بالمنزل
Free at home
بالمنزل بدون عزل
Hospitalized or transferred to another facility
تم تنويمه بالمستشفى أو تمت إحالته إلى منشأة صحية أخرى
Dead
متوفي
2.2 Patient clinical information on admission 2.2المعلومات اإلكلينيكية للمريض عند الدخول للمستشفى
1. Height__________ _cmالطول
2. Weight_______ ._____Kg3 الوزن. Temperature:_ _ Cدرجة الحرارة
4. Heart rate____ نبضات القلب
5. Blood pressure:__ ____ضغط الدم 6. O2 saturation, ………… تركيز
االوكسجين
1. No signs, no movements 2 Mild 3 Moderate 4 Severe
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2.3 Other lab results performed at the time of admission or the most recent results
نتائج الفحوصات المخبرية األخرى عند دخول المريض 3.2 : للمستشفى أو النتائج األحدث
1. White blood cells count 2. Creatinine 3. Lymphocytes %( …...…… )
4. Platelet count 5. Neutrophils %(..…… ) 6. Blood Urea Nitrogen( ) 7.Date:_dd_/_mm__/_yyy y_
2.4 History and Pre-Existing Conditions (Complete even if patient is dead)
1. Is the patient Healthcare worker? Yes No
Unknown
2. If yes, name of HealthCare facility where patient is working: ………………………………………………………………………………
3. If yes, type of the HC worker:
Physician Nurse X-ray technician cleaner
Respiratory rehabilitation therapist Not patient care related
Laboratory worker Other patient care: ………………………
4. Department where working: ICU Radiology Emergency room Outpatient
department
Dialysis Respiratory Rehabilitation
Dept. Other patient care Dept.
___________ 5. Did the patient give care to a MERS patient?
What type of service and contact date…………………………?
Yes
No
Unknown
Non patient care department
6. If not a healthcare worker, did the patient visit any healthcare facilities during the last 14 days before onset of symptoms?
Yes No Unknown
If yes, what healthcare facility:
................................................................................................................................
7. Did the patient have any pre-existing conditions? YES NO UNKNOWN
1. Diabetes Mellitus
2. HIV/other immune deficiency
a. On immune suppressive therapy
b. On glucocorticoids
c. Immune compromising disease
3. Hypertension
4. Heart disease
5. Asthma
6. Chronic liver disease
7. Chronic haematological disorder
8. Chronic lung disease
8. Pregnancy weeks of…………. gestation
9. Chronic kidney disease
10. On dialysis
11. Had kidney transplant
12. Neoplastic disease
14. Other (specify): …………………………………………………………………………………………………………………………………
End of Part 2
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3.2 Complications developed during the hospitalization
Yes No Unknown Date developed
1. Pneumonia _dd_/_mm__/_yyyy _
2. Acute renal failure _dd_/_mm__/_yyyy _
3. ARDS (Acute Respiratory Distress Syndrome)
_dd_/_mm__/_yyyy _
4. Respiratory failure _dd_/_mm__/_yyyy _
5. Cardiac failure _dd_/_mm__/_yyyy _
6. Multi-organ failure _dd_/_mm__/_yyyy _
Other (specify) : ……………………………………………………….. _____dd/_______mm/______yyy
3.3 If transferred to another hospital
1. Name of the hospital transferred to: …………………………………………….. 2. Date of transfer: ___________________
3. Region: 4. City: 5. Sector:
3.4 When discharged from hospital
1. Date of discharge: _dd_/_mm__/_yyyy_
2. Condition: Alive Deceased Against Medical advice
3. Home isolation recommended. Yes No Unknown
4. Public Department of Health office name: 5. Date case transferred to Public Department of Health _dd_/_mm__/_yyyy_
End of Part 3.
6 Complete the Case closure form 7 Complete the Case closure form
Part 3. Follow up form - To be filled upon any status change of the hospitalised patient
3.1 Status update
S. N
Date (dd /mm/yyyy )
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Part 4. Case Close إغالق الحالة : 4الجزء
4.1. Reason for case closure 1.4 أسباب إغالق الحالة
Patient died
وفاة
المريض
Patient discharged
Another infectious disease has been confirmed
شخيص أخر تم تأكيد ت
.
Give number of tests_______حدد عدد العينات
4.2 If died 2.4 إذا توفت الحالة
1. Date of death
تاريخ الوفاة (___dd/___mm/___yyyy )
2. Death certificate number: (___________________ )
رقم وثيقة الوفاة
3. Place of death
مكان الوفاة
At home
بالمنزل
Unknown بالمستشفى
غير معروف
4. Post mortem tests performed?
هل تم إجراء تشريح للجثة
Yes نعم No ال
Comment: Please attach the copy of the death certificate and send it by fax or Email to Public Health
المحافظة /منطقة إدارة الصحة العامة بالالرجاء إرفاق نسخة من شهادة الوفاة وإرسالها بالفاكس أو البريد اإللكتروني إلى : مالحظة
4.3 If discharged 3.4 إذا خرجت الحالة من المستشفى
1. Latest MERS test results
نتيجة أخر تحليل كرونا
Positive
إيجابي
Negative, number of consecutive tests shown negative results prior to discharge___________ سلبية، عدد العينات السلبية قبل خروج الحالة من المستشفى
2. Discharge approved by:
....………………………….. : اسم من اعتمد خروج المريض
Date of discharge تاريخ الخروج
____/_____/___ (dd/ mm /yyyy)
4.4 If another infectious disease has been confirmed
إذا تم تأكيد تشخيص أخر للحالة 4.4
1. Date of confirmation تاريخ تأكيد التشخيص dd/___mm/____yy___الجديد
2. Specific causative agent confirmed: تم تأكيد التشخيص لمسبب أخر، حدد
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MERS CoV Community Surveillance Form (Form # 2)
)2#نموذج ( )فيروس كرونا(اإلستقصاء الوبائي لحاالت متالزمة الشرق األوسط التنفسية
Note for interviewer:
If you are interviewing a patient ask all questions in the first person, If you are interviewing the patient’s relative or contact person ask questions in the third person.
: مالحظة لمن يقوم باالستجواب
. جميع األسئلة تخص المريض فإذا كنت تقابل المريض فأسأله
مباشرة، اما إذا كنت تقابل شخص
من أقرباء المريض فتكون األسئلة
. عن المريض
Date Investigation Start:
تاريخ إجراء
:االستقصاء
Form completed by: اسم من قام بإستكمال
:النموذج
Phone number: رقم الهاتف:
Permanent jobsite: جهة العمل :األساسية
Sectorالقطاع: Health Region المنطقة الصحية:
Part 1. Patient personal information
1. First & Father name: اسم المري
ض
2. Family name: العائلة
):اللقب(
3. GPS coordinates N ................................... E………………… إحداثيات موقع :سكن الحالة
4. Address in detail: العنوان : بالتفصيل
5. What type of housing? Single family home/villa منزل
فيال /منفصل
Apartmentشقة
Dormitoryمجمع سكني
Other, ،أخرى ………………………specifyحدد
ما نوع المنزل الذي يسكنه
المريض ؟
6. Home phone: + ( )_ _ _-_ _ _-_ _ _ 8. Mobile phone: + ( ) Other mobile phone
9. Does the patient have another home?
Yes No نعم هل للمريض منزل أخر؟ ال
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10 If yes: Address _________________________ Telephone Number _____________________________
_________________________رقم التلفون___________________________________ العنوان : إذا كانت اإلجابة نعم
12. Is the patient the head of household?
Yes Noنعم هل المريض هو رب ال العائلة؟
If YES, move to part 1.2 1.2، انتقل الى الجزء نعمإذا كانت اإلجابة بـ
1.1 Head of Household Section 1.1 جزء خاص برب العائلة
1. Name of head of household:
اسم رب
: العائلة
2. Identification Number:
رقم الهوية لرب
: العائلة
National ID هوية وطنية
Iqama إقامة Passport جواز سفر Others اخرى
3. Relationship to patient:
Parent والدة/والد
Spouse العائل
children االطفال
Other, ددأخرى، ح specify……………...........……
صلة القرابة مع
المريض
4. Mobile phone number: + ( )_ _ _-_ _ __ _ _other mobile phone رقم الجوال رب العائلة:
1.2 Patient Social information 1.2 معلومات اجتماعية للمريض
1. Education (Give highest year of school
completed):
Childطفل
Illiterate غير متعلم
Preschool رياض أطفال
Elementaryابتدائي
Intermediateمت وسطة
Secondaryثانوية
Diplomaدبلوم
Bachelorبكالوريو س
Masterماجستير
PHDدكتوراه
الحالة التعليمية
للمريض
سجل اعلى مرحلة ( تعليمية وصل اليها
):المريض
2. Occup ation:
Student طالب
Employed/ Government sector يعمل بالقطاع الحكومي
Employed/ Private sector يعمل بالقطاع الخاص
Retired متقاعد
Unemployed عاطل عن العمل
Otherأخرى,specify…… ……
مهنة
:المريض
3. If student, please provide
Name of the college/school الجامعة/اسم المدرسة :……………………………………
Address العنوان:……………………………………………………………………
إذا كان
طالب،
سجل
4. If employed, please provide:
Name of the employerاسم جهة العمل:
Address العنوان:………………………………………………………………
إذا كان موظفاً،
:التالي سجل
5. Does the patient have Housemate / driver working in the home?
6. Sex….. 7 الجنس. Age…… العمر
Yes No نعم ال
هل المريض لديه
سائق؟/خادمة
If yes, include on contact list
.ان المخالطينإذا كانت اإلجابة نعم، اضف أسمائهم ببي
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Part 2 Personal Risk: عوامل الخطورة الشخصية 2الجزء:
2.1 Smoking 2.1 التدخين
1. Does the patient smoke? Yes No نعم هل المريض ال مدخن؟
2.If yes, Specify: Cigarettesد خان
Nargghile معسل Sheesha ) جراك( شيشة إذا كانت اإلجابة نعم، حدد
Electronic Cigarettes سيجارة الكترونية
3. For how many years?
4. How many per day?
…………………………
كم سنة يدخن؟
كم مرة باليوم؟ …………………………
The following exposure questions cover the 14 days before the patient developed the illness
التالي يتضمن أسئلة تغطي التعرض لعوامل خطورة
يوماً من إصابة المريض 14قبل
2.2. Exposure to possible human sources 2.2التعرض لمصدر عدوى إنساني محتمل
1. Did patient attend any mass gatherings? هل حضر المريض إي تجمع كبير؟
Football or other large sporting eventsمبارة كرة قدم أو حدث رياضي كبير Janadria الجنادرية
Um Rugaibah (Mazaieen-Camel festival) )ام رقيبة(مزايين اإلبل Omra عمرة
Esterahah (extended family gathering) ) تجمع عائلي كبير(إستراحة Hajj حج
Other Specify…….
2.3. Exposure to Human sources 3.2 التعرض لمصدر عدوى إنساني
1. Is the patient a healthcare worker?
Yes هل المريض يعمل بالمجال ال Noنعم الصحي؟
N.B1 If patients a healthcare worker, please make sure HOSPITAL FORM complete section 2.4
إذا كان المريض يعمل بالمجال الصحي، تأكد : 1مالحظة 2.4بأن نموذج المستشفى قد استوفى الجزء
N.B2 If not a healthcare worker, please provide answers to the following questions:
إذا كان المريض ال يعمل بالمجال الصحي، : 2مالحظة :استكمل الجزء التالي من األسئلة
2 .
Did the patient visit for any reason any health care facility during the 14 days before onset of symptoms?
يوم قبل ظهور األعراض؟ 14هل زار المريض أي منشأة صحية ألي سبب كان خالل
Yes Noنعم ال
3 .
Does the patient have regular visits to health care to receive treatments (e.g. renal dialysis, diabetes management, pregnancy, etc)
)الخ... حمل، غسيل كلوي، عيادة السكر، ال: مثال(هل المريض يراجع منشأة صحية بصفة منظمة لتلقي العالج
Yes Noنعم ال
4 .
Did the patient visit a relative, neighbour, employer, co-worker, friend, while they were sick with a respiratory illness?
بالجهاز هل زار المريض اقربائه، جيرانه، موظفيه، زمالئه بالعمل، أصدقائه أو المدرسة اثناء مرضهم
التنفسي
Yes Noنعم ال
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5 . If yes,____
إذا كانت اإلجابة بنعم
Where did this happen? At homeفي المنزل
In a health care facility في منشأة 6 صحية
.
Did the patient provide care for that person?هل قام المريض برعاية ذلك الشخص
Yes Noنعم ال
7. Was any family member diagnosed with MERS Corona virus infection before patient became sick?هل تم تشخيص أحد افراد العائلة بالكروناقبل ظهور األعراض على المريض
Yes Noنعم ال
8. Was any family member diagnosed with MERS Corona virus infection Afterpatient became sick?هل تم تشخيص أحد افراد العائلة بالكرونابعد ظهور األعراض على المريض
Yes Noنعم ال
9. Was any other person who the patient knows personally diagnosed with MERS Corona virus? م تشخيص حالتهم بالكوروناهل هنالك اشخاص يعرفهم المريض ت
Yes Noنعم ال
9.1 Before patient became sick? ظهور األعراض على المريض قبل Yes Noنعم ال
9.2 After patient became sick? ظهور األعراض على المريض بعد Yes Noنعم ال
2.4. Travel History 4.2 تاريخ السفر
1. During the 14 days before patient became sick, did patient travel outside or inside Saudi Arabia?
If yes, complete the following table:
فر يوم قبل ظهور األعراض على المريض، هل سا 14خالل خارج او داخل المملكة ؟
:إذا كانت اإلجابة بنعم، أكمل بيانات الجدول ادناه
Country/City Departure date
Return date Mode of travel
2. During the 3 days before patient became sick or while they were sick, did patient travel outside or inside Saudi Arabia?
If yes, complete the following table:
أيام قبل ظهور األعراض على المريض آو كان 3خالل مريضاً، هل سافر خارج او داخل المملكة ؟
:إذا كانت اإلجابة بنعم، أكمل بيانات الجدول ادناه
Country/City Departure date
Return date Mode of travel
2.5. Exposure to CAMELS 5.2 مخالطة الجمال
1. Does the patient raise camels? Yes Noنعم هل المريض لديه جمال ؟ ال
2. Is the patient’s profession one of the following:
هل المريض يعمل في أحد المجاالت ادناه ؟ ال
Camel -لتاجر جمال Trader Herder يرعى الماشية
Slaughter man ينحر الماشية Butcher جزار
Camel milkier يحلب الجمال Veterinary طبيب بيطري
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Sidewalk meat seller يعمل ببيع اللحوم Camel rider يمتطي الجمال Other specify
3. Do they have any other occupation that regularly deals with camels? هل المريض لديه عمل أخر يختص بالتعامل مع الجمال بصورة منتظمة
Yes ال Noنعم
Specify حدد:…………………
4. During the 14 days before the patient developed the illness did they :
يوم قبل من ظهور األعراض على المريض، هل قام 14خالل ال:بالتالي
Visit a live animal market زار الماشيةسوق
Touch a camel أحتك او لمس جمل
Visit a slaughterhouse زار المسلخ
Ride a camel أمتطى جمل
Attend a camel race حضر سباق )الهجن(جمال
Drink camel milk شرب حليب ابل
Eat raw camel liver or partly cooked camel liverأكل كبدة ابل غير مطهية أو نصف مستوية
Handle raw camel meatتعامل مع لحوم جمال طازجة
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List of patient’s contacts (Please include domestic servants and drivers)
)الرجاء إدراج أسماء العمالة المنزلية من خدم وسائقين ( بيان بالمخالطين للمريض
S.N
ت
Contact name
أسماء المخالطين
Age
العمر
R e
la ti
o n
sh ip
t o
P a
ti e
n t
ض ري
م لل ه
قت ال
ع ة
صف
D a
te s
w a
b T
a ke
n
(S ym
p to
m a
ti c)
ة ح
س م ال ذ
خ أ خ
ري تا
) ض
را ع
ا هم
ب ن
م ل
(
Identific ation
Number
الهويةرقم
Type of Identification
1. …………….. ………… National I.D هوية
Iqamaإقامة
Passport جواز سفر
2. …………….. …………… National I.D هوية
Iqamaإقامة
Passport جواز سفر
3. …………….. …………… National I.D هوية
Iqamaإقامة
Passport جواز سفر
4. …………….. …………… National I.D هوية
Iqamaإقامة
Passport جواز سفر
5. …………….. …………… National I.D هوية
Iqamaإقامة
Passport جواز سفر
6. …………….. …………… National I.D هوية
Iqamaإقامة
Passport از سفرجو
7. …………….. …………… National I.D هوية
Iqamaإقامة
Passport جواز سفر
8. …………….. …………… National I.D هوية
Iqamaإقامة
Passport جواز سفر
9. …………….. …………… National I.D هوية
Iqamaإقامة
Passport جواز سفر
10. …………….. …………… National I.D هوية
Iqamaإقامة
Passport جواز سفر
Note: Complete the table for all of the Contacts includes Housemates & Driver. Add additional page if needed.
سجل جميع المخالطين للحالة اإليجابية بما في ذلك : مالحظة استخدم صفحة أخرى من نفس النموذج . الخادمات والسائقين
.إذا استدعى األمر
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Part 3. Follow up form (To be filled upon any status change of the isolated patient)
)زول بالمنزل يتم تعبئته دورياً أو عند حدوث أي تغيير لحالة المريض المع( سجل متابعة حالة المريض . 3الجزء
S.N
ت
Date
تاريخ اإلتصال
بالمريض (dd
/mm/yyyy )
Method of contact
المريضطريقة اإلتصال ب
Status update تحديث وضع المريض الصحي
No change
ال تغيير
Requires hospitalization
يتطلب إحالته
للمستشفى
Recovered from MERS
CoV8,9
تعافى من
كرونا
Died10
توفى
1. _/_/____ Phone
هاتف Visit زيارة
2. __/__/___ Phone
هاتف Visit زيارة
3. __/__/___ Phone
هاتف Visit زيارة
4. __/__/___ Phone
هاتف Visit زيارة
5. __/__/___ Phone
هاتف Visit زيارة
6. __/__/___ Phone
هاتف Visit زيارة
7. __/__/___ Phone
هاتف Visit زيارة
8. __/__/___ Phone
هاتف Visit زيارة
9. __/__/___ Phone
هاتف Visit زيارة
10. __/__/___ Phone
هاتف Visit زيارة
8 No symptoms for 24 hours and latest swab MERS test is negative 9 Complete the Case closure form
10 Complete the Case closure form
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Part 4. Case Closure إغالق الحالة: 4لجزء
4.1. Reason for case closure 1.4 أسباب إغالق الحالة
Patient died
وفاة المريض
Patient discharged
خروج المريض
Another infectious disease has been confirmed
تم تأكيد تشخيص أخر
. Give number of tests_______ حدد عدد العينات
4.2 If died 2.4 إذا توفت الحالة
1. Date of death__ /__/___ ____
خ الوفاة تاري (dd/ mm/ yyyy )
2. Death certificate number: (……………………. )
رقم وثيقة الوفاة
3. Place of death
مكان الوفاة
At home
بالمنزل
In hospital Unknown
غير معروف
4. Post mortem tests performed?
هل تم إجراء تشريح للجثة
Yes نعم No ال
Comment: please attach the copy of the death certificate and send it by fax or Email to Public Health
المحافظة /مة بالمنطقة الرجاء إرفاق نسخة من شهادة الوفاة وإرسالها بالفاكس أو البريد اإللكتروني إلى إدارة الصحة العا: مالحظة
4.3 If discharged 43. إذا خرجت الحالة من المستشفى
1. Latest MERS test results
نتيجة أخر تحليل كرونا
Positive
إيجابي
Negative, number of consecutive tests shown negative results prior to discharge___________ ، سلبية عدد العينات السلبية قبل خروج الحالة من المستشفى
2. Discharge approved by: ……………........................... اسم من ..…………………………
: اعتمد خروج المريض
Date of discharge
تاريخ الخروج
____/_____/_____
(dd / mm / yyyy )
4.4 If another infectious disease has been confirmed 4.4 إذا تم تأكيد تشخيص أخر للحالة
1. Date of confirmationتاريخ تأكيد التشخيص الجديد____ /___ / _____
(dd / mm / yyyy )
2. Specific causative agent confirmed: تم تأكيد التشخيص لمسبب أخر،
العينات حدد عد
Give number of test
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MERS-CoV Outbreak
Line Listing Record for Household and Other Contacts (Form 3)
Region: _____________ Public Health Investigator: _____________________________________
Personal Data
Record name once and do not remove name from line list
Daily Progress Use Legend: SF=Symptoms Free; F=Fever; C=Cough; N/V=Nausea/Vomiting; BA= Body Aches; H=Headache Died=Death
HOS=Hospitalization Name (To be typed in English
and Arabic) ID/ Iqama number Age Nationality 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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MERS-CoV Outbreak
Line Listing Record for Healthcare Workers Contacts: (Form 4)
Facility: _________________________ Facility Contact:_______________
Personal Data
Record name once and do not
remove name from line list
Daily Progress Use Legend: SF=Symptoms Free; F=Fever; C=Cough; N/V=Nausea/Vomiting; BA= Body Aches; H=Headache
Died=Death HOS=Hospitalization, Test=MERS-CoV tested
N a
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MM/
YY
Day 2
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YY
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YY
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APPENDIX E
Guidelines for MERS-CoV Sample Collection, Packaging and Shipping
APPROPRIATE COLLECTION, TRANSPORTATION AND STORAGE OF THE SAMPLE FOR MERS COV TESTING ACCORDING TO INTERNATIONAL STANDARDS PLAY A MAJOR ROLE
IN THE ACCURACY OF THE RESULT
1. General Considerations:
1.1. Sample collection: Before collecting and handling specimens for Middle East
Respiratory Syndrome Coronavirus (MERS-CoV), determine whether the person meets
the current case definitions for Suspect, Probable or Confirmed cases.
1.2. Appropriate PPE should be worn by all laboratory staff handling these specimens (9.1,
9.2).
1.3. Proper biosafety policies and procedures should be maintained when collecting
specimens (9.1, 9.2).
1.4. Use approved collection methods and equipment when collecting specimens.
1.5. Handle, store, and ship specimens following appropriate protocols.
1.6. It is very important to include patient national, Iqama or passport number in the
request form to help trace records for patients that do doctor shopping. For illegal
residents please put a note in the request which demonstrates that no Iqama is
available due to illegal residency.
2. Specimen type and priority:
2.1. Best upper respiratory tract (URT) specimen is nasopharyngeal (NP) swab or
combined nasopharyngeal and oropharyngeal (NP/OP) swab specimens in (9.3).
2.2. To increase the likelihood of detecting infection, lower respiratory Tract (LRT)
specimens (Sputum, tracheal aspirate (TA), Endotracheal secretions, or Broncheo-
alveolar lavage(BAL)) are preferred. Based on the current data, they are the most
likely to provide positive results. However, this should not exclude another specimen
from the URT to enhance viral detection in challenging samples (9.3).
2.3. Additional specimens such as blood and serum can be collected on presentation and
in convalescence period. (Please refer to specimen collection No.3).
2.4. Respiratory specimens should be collected as soon as possible after symptoms start,
ideally within 7 days and before antiviral medications are administered.
2.5. However, if more than a week has passed since onset of illness and the patient is still
symptomatic, lower respiratory samples are the preferred samples.
2.6. Samples should not be stored in hospitals for more than 4 hours (at 4 – 8oC) before
delivering by the courier. Delivery of MERS-CoV specimens allowed ONLY by the
courier. Specimens pick up SHOULD be requested at the following number (800
6149999).
2.7. Label each specimen container with the unique MERS-CoV number; patient hospital
ID number, specimen type, the date and the time of sample collection include patient
national, Iqama or passport number.
2.8.
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Specimen Collection:
2.9. Use powder-less clean (Non-surgical) gloves when collecting specimens for MERS-CoV
for PCR testing since, trace amount of powder in the sample could inhibit PCR testing
producing false negative result (9.3).
2.10. All specimens should be regarded as potentially infectious, and HCWs, courier,
laboratory personnel who collect, transport, or handle the clinical specimens should
adhere rigorously to standard precautions to minimize the possibility of exposure to
pathogens (9.3).
2.11. Ensure that HCWs who collect specimens should be properly trained on the technique
and wear PPE appropriate for aerosol generating procedures.
2.12. Health caring facilities will assign and train personnel to perform nasopharyngeal
swabbing.
2.13. Respiratory Specimens:
2.13.1. Lower respiratory tract
2.13.1.1. Broncheo-alveolar lavage (BAL), tracheal aspirate (TA) and/or
pleural fluid should be collected whenever clinically appropriate:
Collect 2-3 ml into a sterile, leak-proof, screw-cap sputum
collection cup or sterile dry container. Refrigerate specimen at 2-
8°C up to 48 hours; if exceeding 48 hours, freeze at -70°C and ship
on dry ice.
2.13.1.2. Sputum: (induced or spontaneous) ask the patient to rinse the
mouth with water then expectorate deep cough sputum directly
into a sterile, leak-proof, screw-cap sputum collection cup or
sterile dry container. Refrigerate specimen at 2-8°C up to 48 hours;
if exceeding 48 hours, freeze at -70°C and ship on dry ice.
2.13.1.3. Mucoid specimens such as BAL, TA and sputum can be placed in
VTM after collection to liquefy the specimens and preserve the
trapped virus.
2.13.2. Upper respiratory tract
2.13.2.1. Nasopharyngeal and Oropharyngeal swabs (NP/OP swabs) MUST
BE TAKEN TOGETHER. Use only synthetic fiber swabs with plastic
shafts. Do not use calcium alginate swabs or swabs with wooden
shafts, as they may contain substances that inactivate some
viruses and inhibit PCR testing. Place swabs immediately into
sterile tubes containing 2-3 ml of viral transport media. NP/OP
specimens MUST BE combined, placing both swabs in the same
vial. Refrigerate specimen at 2-8°C up to 48 hours; if exceeding
48 hours, freeze at - 70°C and ship on dry ice.
2.13.2.2. Nasopharyngeal swabs: Insert a swab into the nostril parallel to
the hard palate. Leave the swab in place for a few seconds to
absorb secretions. Swab both nasopharyngeal areas.
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Figure 1: Correct Technique for Taking a Nasopharyngeal swab
For more information see NEJM Procedure: Collection of Nasopharyngeal Specimens with the Swab Technique: http://www.youtube.com/watch?v=DVJNWefmHjE https://youtu.be/CcyLv67U8-Y
2.13.2.3. Oropharyngeal swabs: Swab the posterior pharynx, avoiding the
tongue.
2.13.2.4. Nasopharyngeal wash/aspirate or nasal aspirates: Collect 2-3 ml
into a sterile, leak-proof, screw-cap sputum collection cup or
sterile dry container (If highly mucoid, better collect in VTM
container). Refrigerate specimen at 2-8°C up to 48 hours; if
exceeding 48 hours, freeze at -70°C and ship on dry ice.
2.14. Blood Components
2.14.1. Serum (for Serological testing)
For serum antibody testing: Serum specimens should be collected during the acute stage of the disease, preferably during the first week after onset of illness, and again during convalescence ≥ 3 weeks after the acute sample was collected. However, a single serum sample collected 14 or more days after symptom onset may be beneficial. Serological testing is for research/surveillance purposes and not yet for diagnostic purposes. Currently it is NOT available at the MOH regional laboratories but will be implemented soon.
2.14.2. Serum / Plasma (for rRT-PCR testing) (Not recommended for routine testing):
For rRT-PCR testing (i.e., detection of the virus and not antibodies), a single serum or plasma specimen collected optimally during the first week after symptom onset, preferably within 3-4 days may be also beneficial but is not recommended for routine testing.
2.14.2.1. Serum Specimen:
2.14.2.1.1. Children and adults. Collect 1 tube (5-10 ml) of whole blood
in a serum separator tube. Allow the blood to clot, centrifuge
briefly, and separate sera into sterile tube container. The
minimum amount of serum required for testing is 500 µl.
Refrigerate the specimen at 2-8°C and ship on ice- pack;
freezing and shipment on dry ice is permissible.
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2.14.2.1.2. Infants. A minimum of 1 ml of whole blood is needed for
testing of pediatric patients. If only 1 ml can be obtained, use
a serum separator tube to achieve a minimum of 400 µl
serum sample.
2.14.2.2. EDTA blood (plasma):
Collect 1 tube (10 ml) of EDTA (purple-top) blood. Avoid using heparinized (green-top) blood as this will interfere with the test and inhibit PCR. Refrigerate specimen at 2-8°C and ship on ice pack; do not freeze.
3. Shipping:
3.1. Specimens from suspected MERS-CoV cases must be packed, shipped, and
transported according to the current edition of the International Air Transport
Association (IATA) Dangerous Goods Regulations prepared by IATA licensed laboratory-
personnel (9.4, 9.5).
3.2. At present MERS-CoV diagnostic specimens must be assigned to UN3373 and must be
packaged as Category B infectious substances.
3.3. Packing responsibility is by the sample collection laboratory personnel and the
shipment booking will be scheduled at the collection site in coordination with
receiving laboratory.
3.4. Ensure that personnel who transport specimens are trained in safe handling practices
and spill decontamination procedure.
3.5. Place specimens for transport in leak-proof specimen bags (secondary container) that
have a separate sealable pocket for the specimen (i.e. a plastic biohazard specimen
bag), with the patient’s label on the specimen container (primary container), and a
clearly written request form.
3.6. Ensure that health-care facility laboratories adhere to appropriate biosafety practices
and transport requirements per the type of organism being handled.
3.7. Deliver all specimens by hand whenever possible. Do not use pneumatic tube systems
to transport specimens.
3.8. State the name of the suspected ARI patient of potential concern clearly on the
accompanying request form. Notify the laboratory as soon as possible that the
specimen is being transported.
3.9. Shipment collection must be at Laboratory site. Time of shipment collection must be
documented within AWB.
4. Labeling:
The outer container of all specimen packages must display the following on two opposite sides:
o Sender’s name and address.
o Recipient’s name and address.
o The words “Biological Substance, Category B”.
o UN 3373 label.
o Class 9 label, including UN 1845, and net weight if packaged with dry ice.
5. Packaging:
Specimens must be triple-packaged and compliant with IATA Packing Instruction 650, which is detailed in Figure 1. The maximum quantity for a primary receptacle is 500 ml or 500g and outer packaging must not contain more than 4 L or 4 kg (9.5).
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Figure 2: Packing Instruction Biological Specimens Category B
For more information on proper packaging for biological specimens “category B” see the technique on: https://youtu.be/GJK9FRT4IXM
5.1. Packing Containers
5.1.1. Packages must be of good quality, strong enough to withstand the rigors of
transport.
5.1.2. Triple packaging consisting of leak proof primary receptacles (for liquid
shipments), silt proof primary receptacles (for solid shipments), leak proof
secondary packaging and outer packaging of sufficient strength to meet the
design type test (1.2 meter drop test).
5.1.3. For liquid shipments, primary receptacle or secondary packaging capable of
withstanding a 95Kpa internal pressure differential.
5.1.4. Absorbent material must be sufficient to absorb the entire contents of the
shipment.
5.1.5. An itemized list of contents must be included between the secondary and
outer packaging.
5.1.6. “Biological Substance, Category B” must appear on the package.
5.1.7. Minimum dimension is 100mm.
5.1.8. When large numbers of specimens are being shipped, they should be
organized in a sequential manner in boxes (numerical order of patient
hospital ID) with separate compartments for each specimen.
5.1.9. Patient Data Sheets and an Itemized List of Contents will accompany the
package. The paperwork will be packaged inside the outer package NOT in
the secondary container.
5.1.10. All specimens must be pre-packed to prevent breakage and spillage. Each
specimen container should be sealed with Parafilm (after being crewed
properly) and placed in a separate zip-lock bag.
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5.1.11. Place enough absorbent material to absorb the entire contents of the
Secondary Container (containing Primary Container) and separate the Primary
Containers from each other (containing specimen) to prevent breakage.
5.1.12. Send specimens with cold packs or other refrigerant blocks that are self-
contained (do not use actual wet ice). This prevents the appearance of a spill
due to thawed ice.
5.1.13. The courier will supply specimen transport container.
6. Rejection of packages and samples:
Apply universal rejection policy with emphasizes of the following:
6.1. All rejected samples will be discarded according waste management protocols in the
laboratory, and immediate feedback will be given to the courier and treating
physicians, the treating physician will decide if another sample is necessary).
6.2. Samples are not packaged according to packing instruction P650 as UN3373
Diagnostic Specimens.
6.3. An Itemized list of samples organized by Hospital Patient ID number is NOT included
inside the outer package.
6.4. Any sample received without HESN investigations number printed clearly in request
form will be rejected. In addition, results of samples received without filling MERS-
CoV F117 form will be held till F117 form filled by the sender and informed to the
laboratory.
6.5. Any mismatch or missing data between the specimen and the request form.
6.6. The patient data sheets are incomplete, missing or incorrectly filled out.
6.7. Any leakage or spillage, inside or outside the primary or secondary containers.
6.8. If dry ice is placed in the "Primary Container" or "Secondary Container", foam
envelopes, zip-lock bags, cryo-vial boxes, or hermetically sealed containers.
6.9. If the Primary Containers sideways or upside down in zip-lock bags.
6.10. Primary containers must be packaged securely in an upright position and in the
numerical order used on the Itemized List of contents.
6.11. If red top Secondary Containers for Category A Infectious Substances are used.
6.12. If any paperwork in the Secondary Containers or zip-lock bags.
6.13. The quality of the shipment conditions specially the temperatures of the specimens
(warm).
6.14. Wrong swab; the swabs should not be cotton with wooden shaft as cotton will absorb
the testing material (VTM) and wood could inhibit PCR testing and give false negative
result.
6.15. Expired VTM.
6.16. Delay in specimen’s shipment.
6.17. Blood samples sent in wrong tube, e.g. heparinized (green-top) tube.
7. Turn Around Time (TAT) for Testing MERS CoV:
7.1. TAT up to 24 hours.
7.2. A minimum of 2 runs per day.
7.3. For urgent samples: (Prioritizing) immediately.
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