involved in a possible camel-to-human outbreak. This suggests that airborne transmission of the virus might occur.1,14


Exposures


to the virus might also result from human consumption of un- pasteurized camel milk, camel urine and/or raw or undercooked camel meat.4


Drinking camel milk and urine is not uncommon


in parts of the Middle East. The urine is consumed for allegedly palliative properties. The prophet Mohammed is said to have told his followers to drink camel urine to cure them of disease.15


Because


MERS-CoV is shed in the urine of infected humans, it is plausible that the virus can also be found in camel urine.1


The WHO and


the Ministry of Health Saudi Arabia have issued warnings against drinking camel urine or unpasteurized camel milk and eating raw or undercooked camel meat.4,16 Human-to Human Transmission: Human-to-human trans-


mission of MERS-CoV has been confirmed by epidemiologic and genomic studies and is estimated to account for approxi- mately 60% of MERS cases.2


More than half of these cases have


occurred in healthcare settings where there is close personal contact with infected patients.4,16


This suggests that droplets,


direct contact and fomite transmission routes are likely involved. Some hospital procedures performed on patients with MERS (e.g., cough-generating procedures, bronchoscopy, sputum induction, intubation and extubation, cardiopulmonary resuscitation and open suctioning of airways) can create infectious respiratory aerosols that settle throughout the healthcare environment and on surfaces of medical equipment.17,18


Accordingly, the potential


for transmission of MERS-CoV via contaminated surfaces and fomites is considerable unless careful infection control and pre- vention measures are followed. Coronaviruses are able to remain viable for at least five days on Teflon, polyvinyl chloride (PVC) ceramic tiles, glass and stainless steel.17,18


Conversely, the viruses


are sensitive to heat, lipid solvents, non-ionic detergents, oxidizing agents and ultraviolet light.19 Human-to-human transmission of MERS via exposed individ-


uals (healthcare workers, visitors, family members) who remain asymptomatic, but shed the virus, are also a concern in hospitals where the virus can be transmitted unknowingly through close contact. In one reported case, an asymptomatic 40-year-old healthcare worker was tested following exposure to a patient with MERS. Real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) testing revealed that the healthcare worker continued to shed MERS-CoV for six weeks postexposure.20


At


this time, it is not known if such unrecognized asymptomatic people contribute to the numbers of confirmed infectious cases in communities and healthcare facilities.7


What is close contact? Close contact with a confirmed MERS patient is defined as a household member or a healthcare worker who provides direct patient care or anyone who has prolonged (more than 15 minutes) face-to-face contact with a probable or confirmed case in any closed setting while the patient is ill.1


The Centers for Disease Control and


Prevention defines close contact as being within approximately 6 feet of an ill patient; being within a room or care-area for a prolonged period of time while not wearing protective equipment (gown, gloves, respirator, eye-protection); or having direct contact with infectious secretions while not wearing protective equipment.8


32 Visit us at NURSE.com • 2016


What are the symptoms of MERS-CoV? Once the virus infects the host, the incubation period lasts ap- proximately five days before illness occurs (ranges from two to 14 days), with the severity of the illness varying from asymptomatic or mild respiratory symptoms to severe acute respiratory disease and death. In critically ill patients, the median time from the onset of illness to death is 12 days.6,9


Death has occurred in approximately


35% to 50% of reported patients.9 Patients typically present with symptoms of lower respiratory


infection, with fever (>38 C), chills, headache, myalgia, sore throat, dry or productive cough, shortness of breath, and dyspnea. In severe cases, this can be followed by a rapid progression to viral pneumonia within the first week. Frequently, these patients have developed acute respiratory distress syndrome (ARDS) and severe hypoxemic respiratory failure requiring mechanical ventilation and extracorporeal membrane oxygenation (ECMO).4


The disease


often includes acute renal failure requiring hemodialysis, hepatic inflammation and septic shock with profound hypotension requir- ing vasopressors. Nearly one-third of patients have GI symptoms, including vomiting, nausea and diarrhea.2,4,6,21 Chest radiography is consistent with viral pneumonitis and


ARDS with a spectrum of lower pulmonary infiltrates and con- solidation.1,17


lobes in the early course of illness.4


Lower lobes are affected more frequently than upper Laboratory findings include


thrombocytopenia, lymphopenia, lymphocytosis, neutrophilia and elevated lactase dehydrogenase.17,21


MERS CORONAVIRUS CASE DEFINITIONS22 CONFIRMED CASE


Probable Case


problems are thought to be more susceptible to MERS-CoV.21 virus appears to be more severe in older patients or those with


A person with laboratory confirmation of MERS- CoV infection, irrespective of clinical signs and symptoms.


A febrile acute respiratory illness with clinical, radiological, or histopathological evidence of pulmonary parenchymal disease (e.g., pneu- monia or ARDS AND


Direct epidemiologic link with a confirmed MERS-CoV case AND


Testing for MERS-CoV is unavailable, negative on a single inadequate specimen or inconclusive.


OR


A febrile acute respiratory illness with clinical, radiological, or histopathological evidence of pulmonary parenchymal disease (e.g., pneumo- nia or ARDS) AND


The person resides or travelled in the Middle East, or in countries where MERS-CoV is known to be circulating in dromedary camels or where human infections have occurred recently AND


Testing for MERS-CoV is inconclusive. OR


An acute febrile respiratory illness of any se- verity AND


Direct epidemiologic link with a confirmed MERS-CoV case AND


Testing for MERS-CoV is inconclusive.


Those with underlying medical The


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