comorbidities, such as weakened immune systems, diabetes, obesity, cardiac disease, and chronic renal and lung disease.2


Diagnosis of MERS-CoV in the U.S. It is impossible to distinguish MERS from other severe viral pneu- monias without a travel history linking the patient to the Middle East or a known exposure to a patient with MERS.9


Therefore, in the U.S.,


anyone who presents with fever and pneumonia, or ARDS, and has a history of travel to Middle Eastern countries within 14 days before symptom onset should be evaluated for MERS-CoV. In addition, anyone with symptoms who has had close contact with a symptomatic traveler from these areas should also be evaluated for MERS-CoV infection. Middle Eastern countries include Bahrain, Iraq, Iran, Israel, the West Bank, Gaza, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syria, The United Arab Emirates (UAE), and Yemen.8


Nurses


and physicians who evaluate patients with suspect symptoms and travel histories should be vigilant about communicating their findings to all healthcare professionals who interact with the patient to minimize the risk of infection transmission. It is important to note that fever may not be present in all cases, especially among the elderly, children and the immunocompromised. In the absence of fever, healthcare providers must use signs and symptoms in conjunction with epidemiologic history to determine if MERS-CoV should be considered.23 For suspected MERS cases, the CDC recommends that multiple


specimens from the lower respiratory tract, upper respiratory tract and serum samples be collected from different sites and at different times to increase the likelihood of detecting MERS-CoV.13


Lower


respiratory tract specimens, such as bronchoalveolar lavage fluid, sputum and tracheal aspirates, usually have higher viral loads than upper respiratory tract specimens (i.e., nasopharyngeal swabs).21


Laboratory diagnosis of MERS The first consideration is the number of days since symptom onset and symptoms present at the time of collection. Lab professionals should consult with clinicians to determine these answers. Serum samples and testing: When infection onset is believed to


be within the last 14 days, testing for the virus and NOT the anti- bodies is indicated. A serum separator tube may be used to collect the sample. For rRT-PCR testing, the sample should be centrifuged after clotting and 1 mL serum shipped refrigerated. Because samples need to reach the CDC lab within 72 hours, lab professionals and healthcare providers must coordinate collection times. Laboratory testing for MERS-CoV in local and/or state lab-


oratories may not always be available using the rRT-PCR assay. Respiratory samples and testing: Nasopharyngeal swabs may


be used for testing. The swab must be made of synthetic fiber with viral transport media in the sample container. The swab should be inserted straight back into the nostrils. Oropharyngeal swabs may also be used, swabbing the pharynx,


not the tongue. Bronchial lavage or sputum may also be collected. After rinsing the


mouth, sputum samples can be collected into a sterile container.24 All samples should be shipped refrigerated within 72 hours. Instructions for shipping and handling of MERS specimens per the CDC can be found in the Interim Laboratory Biosafety


2016 • Visit us at NURSE.com 33 The


virus can also be found in blood, urine and feces in lesser amounts.9 MERS infection can be confirmed by rRT-PCR testing.4


Mr. Smith worked in the oil industry in Saudi Arabia. He had just returned home to visit his parents in the U.S. when he developed fever, cough and a shortness of breath. He went to an urgent care facility and was given an asthma inhaler and told to take Tylenol for his fever. He returned home and during the next three days, his fever increased and his breathing became more difficult.


1. Mr. Smith, who was experiencing flu symptoms, went to the ED of the hospital closest to his house and sat for more than three hours in a crowded room filled with others. What should the patient have been asked or told when he presented in the ED? a. Patient should have been told to sit quietly, wait his turn and cover his mouth if he were coughing.


b. Patient should have been asked to sit down and fill out a list of his symptoms.


c. Patient should have been asked whether he had been outside the U.S. in the last month.


d. Patient should have been told to sit as far away from other patients as possible.


2. What should have happened if the patient had indicated he had been in a Middle Eastern country affected by the MERS-coronavirus (MERS-CoV)? a. He should have been given a facemask and moved immedi- ately to an airborne infection isolation room.


b. He should have been given a N-95 filtering face-piece respirator and told to remain sitting in the ED until it was his turn to be seen.


c. He should have been told to remain seated in the ED. The nurse should tell the physician that the patient had been in the Middle East.


d. No special precautions are needed. MERS-CoV is not trans- mitted easily to others.


3. Who will require follow-up if the patient is infected with MERS-CoV? a. Family members and friends of the patient b. Healthcare workers who have had unprotected exposure to the patient


c. Those who had close contact with the MERS-CoV infected patient while waiting in the ED


d. All of the above


Answers


1. C: Anyone who presents to an ED with fever and re- spiratory distress should be asked if he has a history of travel to the Middle East or a known exposure to someone with Middle East respiratory syndrome (MERS) within 14 days before his onset of symptoms. Mr. Smith’s list of symptoms should have alerted healthcare personnel to question him further.


2. A: Patients who might be infected with MERS-CoV should be placed in airborne infection isolation. When entering the room, staff should wear gowns gloves, face shield and an N-95 or higher respirator.


3. D: Anyone who has prolonged (>15 minutes) face-to- face contact with a patient infected with MERS-CoV infected should have follow-up. The Centers for Dis- ease Control and Prevention defines close contact as being within approximately 6 feet of an ill patient, or within a room for a prolonged period of time while not wearing personal protective equipment (PPE).


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