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Call Transcript: CDC Update for Clinicians on Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

Moderators:Leticia R. Davila

Presenters:Susan Gerber, MD, David T. Kuhar, M.D., and Marty Cetron, MD

Date/Time:May 6, 2014 2:00 pm ET

Coordinator:
Welcome and thank you for standing by. At this time all participants are in a listen only mode until the question and answer session of today’s call. Please be advised today’s conference is being recorded. If you have any objections, please disconnect at this time. I would now like to turn the conference over to Miss Leticia Davila - you may begin.

Leticia Davila:
Thank you Melissa. Good afternoon - I am Leticia Davila and I’m representing the Clinician Outreach and Communication Activity (COCA) with the Healthcare Preparedness Activity at the Centers for Disease Control and Prevention. I am delighted to welcome you to today’s COCA Call, CDC Update for Clinicians on Middle East Respiratory Syndrome Coronavirus - MERS-CoV.

We are pleased to have with us today Dr. Sue Gerber, Dr. David Kuhar and Dr. Marty Cetron from the CDC. They will discuss at the epidemiology, clinical signs, and infection control recommendations for MERS-CoV. There is no continuing education or slides provided for this call. Additional resources for clinicians are available on our COCA Website at emergency.cdc.gov/coca under the call page.

At the end of the presentation, you will have the opportunity to ask the presenters questions. On the phone dialing Star 1 will put you in the key for questions. Questions will be limited to clinicians who would like information on clinical guidance related to MERS-CoV. For those who have media questions please contact CDC Media Relations at 404-639-3286 or send an email to media@cdc.gov.

Our first presenter today is Dr. Susan Gerber. She’s the team lead for the Respiratory Viruses and Picornavirus Team in the Division of Viral Diseases at the CDC. She received her MD from Loyola University and completed a pediatric residency and pediatric infectious disease fellowship at the University of Chicago. She has over 13 years' experience in local public health at work and on communicable diseases at the Cook County Department of Public Health and the Chicago Department of Public Health.

Our second presenter Dr. David Kuhar is the Medical Officer in the Division of Healthcare Quality Promotion at the CDC. He received his MD from Emery University, completed his residency in internal medicine at New York University Medical Center and completed a fellowship in infectious diseases at Mt. Sinai Medical Center in New York. Dr. Kuhar came to CDC in 2010. As part of his role at CDC, he served as a subject matter expert on emerging pathogens, develops clinical guidelines regarding infection prevention in healthcare settings, and participates in investigations of infectious diseases outbreaks in healthcare.

Our final presenter is Dr. Marty Cetron. He is the Director for the Division of Global Migration and Quarantine who provides leadership for science, program and policy development in global migration and health. Through his leadership the division works to prevent the introduction and spread of infectious diseases into the United States and to prevent morbidity and mortality among globally mobile populations. Dr. Cetron came to CDC in 1992 as an Epidemic Intelligence Service Officer. He has led several domestic and international outbreak investigations, conducted epidemiologic research, and was involved in domestic and international emergency responses.

In addition today’s presenters Kelly Holton from CDC’s Travelers Health will be available to answer any questions during the Q & A session of today’s COCA call. At this time, please welcome Dr. Gerber.

Dr. Susan Gerber:
Thank you. I’m going to start with a summary about human coronavirus. Human coronaviruses are envelope-positive stranded RNA viruses, and human coronaviruses were first isolated in the 1960s. There are six human coronaviruses that have been identified to date – 229E, OC43, NL63, HKU1, about 11 years ago, the SARS coronavirus, and more recently the MERS coronavirus.

The clinical spectrum of the common human coronaviruses - 229E, NL63, OC43 and HKU1 are common and ubiquitous and most often are associated with upper respiratory tract infections in children. They’ve also been associated with pneumonia and lower tract infections in immunocompromised individuals and the elderly, and they may play a role in exacerbations of underlying respiratory diseases.

Going back to SARS - it was first recognized in November of 2002 with sporadic cases in Guangdong Province, China. The outbreak period for SARS was 2002 to 2003. In addition a Hong Kong hotel contributed to spread a virus to several countries. 8,098 probable SARS cases were documented with 774 deaths. For SARS, the incubation period was thought to be two to 10 days with a median of four days. Transmission was thought to occur through droplets and there were questions about aerosol spread, fomites, and fecal-respiratory transmission was hypothesized in an apartment complex in Hong Kong. Transmission for SARS was most likely during the second week of illness, and there was documentation of super-spreading events or persons who transmitted virus to multiple individuals.

Now switching to MERS-CoV and talking about the first identification of the first case in a 60-year-old man who presented in June of 2012 with a seven-day history of fever and cough and recent shortness of breath in Saudi Arabia. The patient developed acute respiratory distress syndrome and multi-organ dysfunction system and died also a couple of weeks later in June. There were no close contacts with severe illnesses reported, and that’s from a paper in Zaki, et al and that was published a few months later.

Around this time, a second case was identified in a 49-year-old Qatari national who had onset of illness on September 3rd with mild respiratory systems. And subsequently, became very ill and became fully dependent on ECMO. This particular patient also had a remote travel to Saudi Arabia, but - in Qatar had a history of farm, including camels and sheep, exposure, but no history of direct contact with these animals. Virus from the second case was compared to virus isolated from lung tissue of the first case and over the sequence that was - part of the genome that was sequenced - was found to - there was 99.5% identity.

Thus, this virus, MERS Coronavirus, was subsequently named the Middle East Respiratory Syndrome Coronavirus and was found to be a beta coronavirus that was different than SARS. In the timeline of the MERS Coronavirus, the first known cases that have been documented – were documented retrospectively. In two cases associated with respiratory illness in a hospital in Jordan in April of 2012, subsequently, the first identification of the two cases I mentioned in September 2012. Over the time it was clear that there was person-to-person transmission in family clusters in Saudi Arabia and the United Kingdom, and a healthcare facility cluster in Saudi Arabia in April and May of 2013.

In addition more cases became - more countries were known to have persons who were ill with exposures including - I mentioned Saudi Arabia, Qatar, United Arab Emirates and Oman, Kuwait and Jordan. More recently there have been nosocomial outbreaks of illness in Jeddah and more cases that have been reported from Saudi Arabia and the United Arab Emirates, and more recently a first case with exposure from Saudi Arabia reported in the United States.

Some background about the epidemiology of zoonotic exposures, from Memish, et al in November of 2013, 100% found 100% match of 190 nucleotide fragments from a bat near the first - near the home from the first identified case in Saudi Arabia. And this bat fragment was indistinguishable in the short nucleotide sequence from the same sequence of MERS-CoV. Subsequently other bat studies have shown similar viruses where most recently from Ithete, et al showed bats from South Africa that was similar to MERS-CoV and indeed there are other bat viruses including HKU4 and HKU5 that are similar to MERS-CoV.

Switching now to camels…MERS-CoV neutralizing serum antibodies in dromedary camels was first found by Rensken, et al over last summer in 2013. Fifty of 50 sera from Omani camels and 15 or 14 percent of sera from Spanish camels had antibodies to the MERS-CoV spike protein - that was the first evidence of dromedary camels that may play a role in MERS-CoV transmission.

Subsequently MERS-CoV neutralizing antibodies in dromedary camels have been identified in Oman, Spain, United Arab Emirates since 2003, Egypt, Jordan, Saudi Arabia since 1992 and more recently Nigeria, Tunisia and Ethiopia. In addition, MERS-CoV sequences have been identified in dromedary camels associated with two human cases in Qatar - described in a paper by Haagmans, et al. There were three camels with confirmed MERS-CoV sequences and these were similar to the two reported human cases from the same farm. Since then MERS-CoV sequences have been detected in dromedary camels from Qatar, Saudi Arabia, Egypt and Oman.

Switching now to overall human epidemiology. According to WHO confirmation, WHO has confirmed 261 laboratory-confirmed cases with 93 deaths or 36% case fatality rate. There have been many more cases reported by Ministries of Health in the last few weeks. The most recent confirmed onset by WHO has been April 19th. There is a male preponderance and reportedly a 178 males, 77 females and 6 unknown gender. The medium age has been reported as 50 years with a range of 2 to 94 years, and most of the cases have been reported with comorbidities. All cases have an epidemiologic link to six (countries): Saudi Arabia, Qatar, United Arab Emirates, Jordon, Oman and Kuwait.

Talking about more clinical information from the reported cases to WHO that have been confirmed, 12 are children, 2 to 18 years, or 5%. One death in a 2-year-old with chronic pulmonary disease and severe acute respiratory illness in a 14-year-old who had underlying cardiac disease. Four cases were reported with mild symptoms, and six were found to be asymptomatic. Ten of the 12 cases were identified as part of contact investigations.

Recently MERS-CoV cases have been reported by Ministries of Health in Saudi Arabia and United Arab Emirates, and Saudi Arabia has reported hospital and healthcare worker cases from Jeddah, several cases reported from Riyadh, and other regions reporting less numbers of cases. In addition United Arab Emirates there have been increased reports from Abu Dhabi. Imported cases have recently been described, that have been identified in - associated with exposure in Saudi Arabia, in Greece, Malaysia, Egypt, Jordon and the United States.

The first MERS-CoV case that has been identified in the United States is a patient who is an older adult - who traveled from Riyadh, Saudi Arabia to Indiana on April 24, 2014 and associated with a plane trip through London. Was admitted on April 28th and the presenting symptoms were fever, cough, shortness of breath, and went through the emergency department.

Talking about human-to-human transmission of MERS-CoV has been well documented. Overall epidemiology of confirmed cases has identified 26 spacial temporal clusters - all of these clusters have been associated with household and healthcare settings. The medium incubation period has been found to be just over five days with a range of two to 14 days, and routes of transmission at this time are unknown. At this time there is no clear evidence of sustained community transmission.

Some notable clusters, the first cluster identified retrospectively was in Jordan in April 2012 - two confirmed cases - both were fatal - associated with a total of 13 cases among respiratory illnesses, mostly among healthcare workers from Hijawi, et al. Notably more recently in collaboration with the Jordan Ministry of Health - published a report by Payne, et al of a 39-year-old woman who was a contact of one confirmed case and another serological positive case - a close contact - who actually had respiratory symptoms and went on to have a stillbirth at approximately five months gestation.

The fever and respiratory symptoms immediately preceded the stillbirth, and this particular woman was found to be positive by three serologic tests and it is thought that it is possible that a stillbirth may have been associated with this infection. In addition the United Kingdom has published a cluster of an index case to two family members, a French cluster, and a hospital cluster in Saudi Arabia from May - April in which there was transmission to 23 individuals and multiple introductions.

In terms of the clinical information that has been published thus far on MERS-CoV include a series of 47 patients from Assiri, et al of which 28 were deaths, or 60%; all patients had abnormal chest x-rays; 36, or 77%, were male; 46 adults; one child; and close to half of these cases were part of the outbreak in eastern Saudi Arabia. In addition more recently from a paper in Annals of Internal Medicine by Arabi, et al in March 2014 were clinical illnesses described in 12 patients.

All 12 patients had comorbidities, and nine, or 75%, patients had lymphopenia on day one, 11 had lymphopenia during ICU stay, thrombocytopenia noted in two patients on day one and in seven patients during the ICU stay. All twelve patients presented with underlying comorbid conditions, and all presented with acute severe hypoxemic respiratory failure. Most patients, or 11 of 12, had extrapulmonary manifestations including shock, acute kidney injury, and thrombocytopenia. Five, or 42%, were alive at day 90.

Switching back to reported cases to WHO.  In addition we know of reports, that have been confirmed by WHO, of 63 mild and asymptomatic cases. These cases have been identified mostly as part of contact investigations. They have not been described as being hospitalized, but some have been described as having influenza like illness or no symptoms. Some cases have been reported as PCR positive on different days. These cases are not yet known to be implicated or not implicated in transmission, and no cases have been reported to be antibody positive. In the overall 261 WHO-confirmed cases, 59, or 23%, have been described as healthcare workers. Seven of 59 have been described as deaths, and 26 reported as asymptomatic, 13 with mild illnesses and nine reported with comorbidities.

In terms of CDC case definition, for surveillance, is a patient under investigation. And this is how - United States recommendations to actually identify a patient to be tested for MERS. A patient to be tested - to be considered to be tested for MERS, is a patient with severe acute respiratory illness or (SARI) within 14 days of travel from countries in or near the Arabian Peninsula, including close contacts of a symptomatic traveler, symptomatic being fever and respiratory symptoms, a recent traveler from the same area, and close contacts of a confirmed or probable case. In addition, clusters of severe acute respiratory illness no matter where they are from, if no clear etiology is known, those cases can be considered to be tested for MERS.

In addition, a close contact is considered to be a household contact, a healthcare provider not adhering to recommended PPE, and/or close physical contact or face-to-face contact. Monitoring close contacts of confirmed or probable cases would include fever or respiratory symptoms during the 14-day exposure, and these kinds of recommendations would be in coordination with state and local health departments.

Consideration for lab testing are the number of days between specimen collection and symptom onset, symptoms, and time of specimen collection. Lower respiratory specimens, including sputum, bronchoalveolar lavage and endotracheal specimens, are priority respiratory specimens for real time reverse transcription polymerase chain reaction testing. But, including lower tract specimens, it is recommended for patients under investigation that lower and upper tract respiratory specimens including nasalpharyngeal and oral pharyngeal swap, dual rectal swab and serum specimens also be collected. And it may be appropriate depending on clinical presentation to collect specimens at different times.

In addition, CDC has deployed the PCR – rRT-PCR assays to several states and these assays are also available at CDC and have internal confirmation within and include PCR of three gene targets. In addition, CDC has developed capacity of serologic assays including ELISA, immunofluorescence, and microneutralization. These serologic assays in combination may be useful in diagnosis. Treatment options under investigation include convalescent plasma, interferon/ribavirin, protease inhibitors, and mycophenolic acid. In addition, vaccine development is under way.

So where are we now? There are investigations of increased reports of cases. It is important for sequencing of recent viruses, risk factors for transmission in healthcare, natural history of infection, and better defining the modes of transmission from both animals and other humans, and to understand whether or not this virus is seasonal, how it is spread in the healthcare setting and monitor changes in the virus. Thank you.

Leticia Davila:
Our next presenter please.

Dr. David Kuhar:
Hi, this is David Kuhar. CDC posted infection prevention and control recommendations for hospitalized patients in the United States with known or suspected MERS-CoV on its website in June 2013. Standard contact and airborne precautions are recommended for management of these hospitalized patients. It should be noted that these recommendations are consistent with those recommended for the coronavirus that caused SARS, or severe acute respiratory syndrome. The recommendations were based upon available information and the following considerations: the suspected high rate of morbidity and mortality among infected patients, evidence of limited human-to-human transmission, poorly characterized clinical signs and symptoms, unknown modes of transmission of MERS-CoV and lack of a vaccine in chemoprophylaxis.

To quickly summarize the main points in the recommendations, patients should be placed in airborne infection isolation rooms when hospitalized. Patient movement outside of airborne isolation rooms should be limited to medically essential purposes. When transported outside of an airborne isolation room, the patient should wear a face mask for source control. Healthcare personnel should wear appropriate personal protective equipment when entering the patient care area, including gloves, gowns, eye protection, and respiratory protection at least as protective as an N95 respirator.

For environmental infection control standard procedures for hospital policy and manufacturer instructions should be maintained for cleaning and disinfection of surfaces and equipment, textiles and laundry, and food utensils or dishware. As we learn more about the transmission of MERS-CoV guidance updates may be posted. Thank you.

Leticia Davila:
And our final presenter.

Dr. Marty Cetron:
Hi, this is Marty Cetron from CDC’s Global Migration and Quarantine. I just want to leave you with a few thoughts. CDC and the US government recently launched its Global Health Security agenda which is based on three pillars of prevent, detect, and respond. And in that regard clinicians play the frontline role in each of those three categories. And part of the purpose of this call is for you to have the tools and education and insight you need to be able to be partners in public health and the global health security agenda.

Just to give you a sense for how interconnected our world is, we’ve been doing some risk analysis just looking at travel from the Arabian Peninsula, particularly KSA and UAE where the epidemic seems to be increasing, to the United States just for the months of May and June. And it’s notable, that a handful of cities make up over 100,000 arrivals in those two months.

So I think that one of the messages is that this is really not so far away and we’re reminded of that by the case in Indiana. This was perhaps the first introduction that we knew about, but it’s not necessarily likely to be the last, and your ability to be prepared and recognize these cases, just like the able team in Indiana, is going to be key to containing this disease.

Right now there’s no direct treatment, and there’s no direct vaccine to prevent MERS, and so our best strategy is rapid detection and rapid containment through the techniques that were mentioned here. Adept contact tracing, isolation, and even monitoring contacts for a period of 14 days, is essentially the key public health strategy for global health security.

I also want to emphasize the importance for clinicians in taking a travel history. It’s really important - not only to ask where your patient’s been if they don’t volunteer it, or occasionally patients will present inability to give - offer that up on their own, and so getting that travel history whether from the patient or a family is critical. In that history we need to know the full itinerary, where people have been, where they’ve gone. It’s important to document and understand the person’s country of birth as well as their country of residence and sometimes the country of citizenship.

And frequently in the globalized world those aren’t all the same place. Equally important we need to know where the locations of exposure are, the locations of diagnosis, and the locations of care. All of those things are important to prevent, detect, and respond.  And also increasingly, in a mobilized world, those locations of exposure, diagnosis, or ongoing care and treatment may not be in the same place. And the ability to coordinate that across many jurisdictions is very, very important.

To this end we’ve recently posted increased guidance and - increased our alert level for people traveling to the Arabian Peninsula. You can find this on our website (http://www.cdc.gov/travel). And we’ve also posted some special precautions for an increasing number of healthcare workers that are drawn in to working outside their countries of origin or residence, and much like the case of this patient -we have a healthcare worker who was working in a hospital that likely was caring for MERS patients.

Sometimes you may not even know as a healthcare worker the diagnosis of all those patients that you’re taking care of and emergency room encounters or other encounters with undiagnosed patients could pose a risk so using these universal precautions at all times - especially in risk setting is particularly important.

And finally, let me mention an asset and a resource to clinicians out there. We have 20 quarantine stations across the US in the largest international receiving cities, but they’re responsible for over 400 ports of entry and can be your partners in the state, even if your state doesn’t have a quarantine station. It’s worthwhile looking up on our website and seeing the jurisdictional map and knowing what the nearest station is to your area, and they can provide a lot of direct firsthand assistance.

To that end we also have partners at our ports with CBP (Customs and Border Patrol) and TSA officials who are serving as eyes and ears in this global health security agenda as well, and we’ve increased our educational message with these port partners. And so your patients may see signage and information or even receive handouts or things like that as they travel internationally and cross ports.

We’re reminding people that if they do develop signs or symptoms compatible with MERS or any other serious infectious disease, within 14 days of travel, not only should they reach out to the clinicians to see them, but to call ahead in advance and make arrangements to be transported and seen and receive personal protection in the emergency room before inadvertent exposures occur.

So to sum up - we’re in a globalized world - our responsibility as clinicians to participate in global health security gives us the mandate to prevent, detect, and respond. And the best way to do that with regard to MERS is making sure that you’re awareness of the compatible signs and symptoms and a good travel history are frontline in your encounter with patients. Thank you.

Leticia Davila:
Thank you doctors Gerber, Kuhar and Cetron for providing our COCA audience with such a wealth of information. As a reminder Kelly Holton from CDC is available to answer any questions you may have. We will now open up the lines for the question and answer session. Please remember questions will be limited to clinicians who would like information on clinical guidance related to MERS-CoV. For those who have media questions, please contact CDC Media Relations at 404-639-3286 or send an email to media@cdc.gov. Operator?

Coordinator:
We have received today’s first question - one moment please. The first question comes from (Ellen Notashema) - you line is open.

(Ellen Notashema):
Hello, I have a couple of questions. We have a couple of cases recently that we had to test for MERS-CoV and one of our health departments has another of these patients that basically returned from Egypt and has some respiratory symptoms. Can you give us a little bit more guidance on who really needs to be tested? And the second question is for contacts to the Indiana case, how long did it have to stay under home isolation? We tested them negative for MERS-CoV, but, you know, how long did they have to stay in isolation?

Dr. Sue Gerber:
Hi, in reference to the first question about who should be tested for MERS-CoV, it would be an individual who had severe acute respiratory illness with a history of an exposure to the Arabian Peninsula or neighboring countries within a 14 day period. And we do recommend, I should say -- testing for MERS-CoV and it’s not necessary to wait to rule out other infections. It’s important to actually test for other types of etiologies but you don’t need to wait to test for MERS-CoV.

But once somebody tests negative for MERS-CoV and if the clinical course suggests a diagnosis and we’re confident that we have good specimens at good times for MERS-CoV, then it is not necessarily true that that patient would have to be isolated. However, during - all patients under investigation whether they’re, you know, most would be in the hospital should have the infection control precautions as Dr. Kuhar stated and would be isolated. But that’s why it’s important to identify these patients that need to be tested and test them appropriately.

Dr. Marty Cetron:
And, I think you asked, “in the setting of the Indiana case, how long were the contacts under observation?” And that was for a full incubation period of 14 days. Twice-a-day fever checks and symptom checks for contacts. That’s of contacts of a confirmed case not just contacts of a person under investigation or a suspected case.

Leticia Davila:
Operator next question please.

Coordinator:
At this time we’ve received several other questions, however participants have not recorded their names. I don’t have a way by which to introduce their questions. I’ll ask that you dial Star 2 to withdraw the question and redial Star 1 and record your first and last name clearly when prompted so that I may introduce your question.

Leticia Davila:
While we wait for the questions we do have another question that has come through - how do you define different types of contact groups?

Dr. Sue Gerber:
Hi - evaluation of exposures that would inform risk of contact groups should be in coordination with state and local health departments and a lot of this has to do with evaluating face-to-face contact, especially for a prolonged period of time. An example would include a person who is taking care of a confirmed MERS patient in a healthcare setting with inadequate or not adequate personal protective equipment. That would be one example. Another example of a close contact would include a household contact or someone who lives with the patient. Those types of close contacts would be at high risk. A close contact is not someone walking by on the street. A close contact is someone who comes into contact with a MERS-CoV patient face-to-face.

Dr. Marty Cetron:
And to date, person-to-person transmission has been greatest among household contacts and healthcare worker type of contacts to give a sense of setting, not casual community exposures regardless of the physical, you know, proximity in that regard. And so as an example we are considering the potential contacts on an airplane to be very different from the contacts in a healthcare worker setting or in a household.

Leticia Davila:
Thank you. Operator we will go ahead and take the questions that do not have a name. And as a reminder for the subject matter experts if you can please state your names before you answer the question. Operator?

Coordinator:
All right so we have another question from Dr. (Tutella) - his line is now open.

Dr. (Tutella):
Yes - hi - I want to ask how long you keep the patients in isolation precautions for? And number two is - I wanted some clarification, the Indiana patient was a healthcare worker and is that how he was exposed?

Dr. David Kuhar:
This is David Kuhar to address the duration of recommended isolation precautions, currently we do not have a set recommendation for duration of isolation precautions, and we’re determining this on a case-by-case basis primarily based upon duration of viral shedding from body sites.

Dr. Sue Gerber:
This patient is known to be a healthcare provider.

Dr. (Tutella):
Thank you.

Leticia Davila:
Next question please.

Coordinator:
Our next question is from (Susan Flores) - your line is now open.

(Susan Flores):
How do we test for the MERS-CoV? Do we do nasal swabs? Do you all have a specific blood test? And also on the durations of viral shedding - since this is new,  how long would we consider or do we have to retest for viral shedding?

Dr. Susan Gerber:
Hi this is Dr. Gerber we have some information and guidance for laboratory testing for MERS-CoV on our website, but it would include - most - if possible - a lower respiratory tract specimen such as a sputum or an endotracheal specimen - that would be the most important specimen, but we also, for work ups to rule out MERS-CoV, do request nasopharyngeal and oropharyngeal swab specimens in addition to serum for PCR, and if the time is right, that serum could also be tested for antibodies - usually that might be important 14 days from onset, and in addition, stool specimens.

These are the types of specimens that we would actually perform rRT-PCR on of which we have an assay at CDC, but many state health departments are also equipped to do this assay - run this assay as well. However, serologic testing at this point is done at CDC. And in terms of isolation viral shedding - right now - as Dr. Kuhar has said - it’s a case-by-case basis, and there is not enough information that has been documented to better understand how long patients shed and that shedding’s role in transmission to potentially others. So right now it’s a case-by-case basis.

Leticia Davila:
Operator next question please.

Coordinator:
Our next question is from (Peter Vanhorn) - your line is now open.

(Peter Vanhorn):
Good afternoon - the question I have is, are the regional or state MERS-CoV holding centers mentioned earlier, are they going to be equipped to be able to house inmates? Thank you.

Dr. Marty Cetron:
Could you repeat the question - I don’t think we understood on this end at CDC?

(Peter Vanhorn):
Can you hear me now?

Dr. Marty Cetron:
We can hear you, but I don’t think we understood the question.

(Peter Vanhorn):
Great - my question was, are the regional or state MERS-CoV holding centers or the like that you mentioned earlier in major metropolis areas, are they housed or equipped to be able to treat and hold inmates as opposed to regular civilians? Thank you.

Dr. Marty Cetron:
I think I’ve been misunderstood. The CDC quarantine station is also really border health stations - they’re not holding centers or detention facilities of that nature. They are public health centers largely at airports, some cases at ground crossings designed to work with other federal partners to provide information, assessment of ill travelers and so on. But they are not detention facilities and they’re not actually locations of prolonged isolation or quarantine.

That sometimes is misunderstood. So these are public health distribution points at international airports where there is a large volume of arrival in order to be able to coordinate illness on conveyances and they also work very importantly with state and local health departments in increasing preparedness to dealing with illness in mobile populations. But they’re not as you might think or implied by the term. They’re not hospital isolation centers or detention facilities. Think of them more as public health outposts.

Leticia Davila:
Okay - next question and operator you can go ahead and keep bringing in the questions please.

Coordinator:
Surely. Our next question is from (Carol Lee Regal) - your line is now open.

(Carol Lee Regal):
Hello, yes, my question was when you were talking about the close contacts for confirmed MERS cases, what are the recommendations for those individuals? What are we telling the individuals to do? To stay home and have their temperatures monitored? But is that, what exactly are the recommendations for those? And then the second part of my question is I caught a little bit about the treatment options, but could you repeat it because I did not understand all of the available options?

Dr. Susan Gerber:
Hi, this is Dr. Gerber. Right now close-contact recommendations are being made on a case-by-case basis with evaluation of risk of exposure. And the examples are household contacts and healthcare workers who have not worn, or with not adequate, PPE or person protective equipment.

And right now those particular groups are recommended to maybe - it may include either wearing surgical masks during the 14-day period, it could also include being home. Right now it actually - those kinds of recommendations are made by risk assessment and there are no actual recommendations that are for everybody or in every situation, and this is just in general. And right now as we learn more about this virus and its transmission we are making these types of assessments on a case-by-case basis.

In addition it’s a very important to stress that during the 14-day exposure period, it is important that close contacts monitor their health including identification of fever and also clinical symptoms especially respiratory tract systems.

Coordinator:
Our next question is from (Karen Tremberger).

Dr. Susan Gerber:
This is Dr. Gerber again - may I just clarify one issue - the treatment options under investigation are not treatment options for which there is data - there are no - to clarify - there are no treatments known that have been proven for efficacy for MERS-CoV infections. These were for investigation and they include convalescent plasma and other anti-virals and interferon, but they’re only under investigation and research.

(Carol Lee Regal):
Thank you.

Coordinator:
Our next question is from (Karen Tremberger) - your line is open.

(Karen Tremberger):
Hi, I just wanted to clarify something that I thought I heard you say - on the stool - the guidelines say stool specimen - I believe - but I thought I heard stool swabs so I wanted to clarify what you were actually wanting. And then if a healthcare worker has been exposed and they are to stay home how long should they remain off of work?

Dr. Susan Gerber:
Hi this is Dr. Gerber - the stool specimen may be a swab - it could also be stool and it’s important to coordinate with the other specimens with local and state public health. The other question is how long is the time that, for monitoring or potential recommendations for being at home for close contact of a confirmed patient - that would be potentially 14 days out from the last exposure and these would be for very high-risk exposures. Go ahead...

Dr. David Kuhar:
This is David Kuhar – but keep in mind we still do not have a set recommendation for how to manage exposed personnel and the approach may change over time as we learn about the transmissibility of MERS-CoV.

(Karen Tremberger):
Okay thank you - yes - I just wanted to have an idea - trying to get some education put together to give to staff - thank you.

Coordinator:
Our next question is from (Suzanne Sesstuli) - your line is open.

(Suzanne Sesstuli):
Thank you - I was just wondering from the time the specimen leaves the hospital and gets to the CDC - what’s the turnaround time on the test results? And the second part of my question is - if it comes out negative would you still leave them in full isolation?

Dr. Susan Gerber:
Hi, this is Dr. Gerber - we have confidence in our PCR assay to tell us if MERS-CoV is present in that specimen. There are other important things to consider in terms of handling the specimens – at what point are the specimens obtained in the clinical illness from onset of symptoms. And all of these may play a part in trying to interpret results of any laboratory tests, but we have confidence in our testing - in our test for - to detect the presence of MERS-CoV.

And the turnaround time is generally for most labs that actually have PCR can do it in a matter of hours and so hopefully within a day that kind of test should be completed.

(Suzanne Sesstuli):
Okay - thank you.

Coordinator:
Our next question is from (Yancy Hubble) - your line is open.

(Yancy Hubble):
Yes my question is about visitors - do you allow visitors for patients who are admitted with MERS and if you do what kind of person protected equipment should they wear?

Dr. David Kuhar:
Currently we did not address visitor policies in our limited recommendations, however, I would say we should, none the less, we’d limit personnel and patients having contact with patients to personnel who are essential for care and I would say to visitors who are essential for the patient’s well-being.

Coordinator:
Our next is from (Leanne O’Connell) - your line is open.

(Leanne O’Connell):
We would want to know if you have an idea if they can shed the virus early on in - before they’re symptomatic or is it only when they’re symptomatic that they’re able to spread?

Dr. Susan Gerber:
Hi, this is Dr. Gerber. We do not have information that really tells us about the degree of shedding at different time points in the clinical illness especially we do not have any data to suggest that persons shed before symptoms - we do not have that data at this time. However, we’re constantly learning more information about this virus. But right now we do not have adequate shedding studies to inform the peak time when someone might shed that would be important for transmissibility.

Coordinator:
Our next question is from (Jackie Moltrain) - your line is now open.

(Jackie Moltrain):
Is about what the turnaround time would be - so that question has been answered - thank you.

Coordinator:
Our next question will be from (Sheldon Campbell) - your line is open.

(Sheldon Campbell):
Thank you. What do you know about the presence MERS-CoV in non-respiratory body fluids? And are there any recommendations for laboratory workers handling routine blood, urine, stool specimens from patients who are either ruled out or confirmed with MERS-CoV?

Dr. Susan Gerber:
This is Dr. Gerber. MERS-CoV has been detected in specimens other than respiratory specimens, has been detected by PCR in serum and in stool, so it has been detected in other body specimens.

Dr. David Kuhar:
This is David Kuhar for the second part of the question regarding recommendations for laboratory workers. It is actually on the MERS-CoV website under - recommendations are there under the bio safety section.

Coordinator:
Our next question is from (Matthew Simon) - you line is open - I’m sorry...

Leticia Davila:
Before we go to the next question can you please let me know how many we have in queue?

Coordinator:
There are currently four others after Mr. Simon.

Leticia Davila:
Okay perfect we take the couple of questions and end at 3:00.

Coordinator:
Thank you. Mr. (Simon) your line is open.

(Matthew Simon):
Yes - hi - I’ve worked at a hospital in New York that sees a decent number of travelers from this region including people come here for bone marrow transplants. Can you discuss a little bit about presentation and immunocompromised patients? I know, I think, in France they reported someone who had primary gastrointestinal manifestations. And also with visitors coming in and out if we need testing on someone who may not precisely fit the case definition.

Dr. Susan Gerber:
Hi, this is Dr. Gerber. There have been described - most patients have been described with comorbidities, and patients do have - and those would include patients who had immunocompromisations, and it seems at least to appear that patients who are immunocompromised would be more likely to have severe symptoms and may be more likely to acquire noticeable viral illnesses from this virus.

So it does seem apparent that these patients are likely to be more ill. In terms of the French patient did present initially with diarrhea and it’s possible, and we don’t have enough data, but it may be associated with this viral infection and indeed approximately 20 to 25% of patients that have been described where we know some clinical information - have been described has having diarrhea or gastrointestinal symptoms as part of their clinical picture. But it is unknown, because of the comorbidities, if gastrointestinal symptoms such as diarrhea may be more due, or due to underlying illnesses. So more study needs to determine and...

Dr. Marty Cetron:
I mean - this is Dr. Cetron - just recall with SARS Coronavirus up to 25% of patients had diarrhea as a prominent feature, and stool cultures had been positive for Coronavirus - SARS Coronavirus in that setting. So I think your point is “do we need to be vigilant to think outside of the standard way things are presenting in special populations like immunocompromised populations?” and I think that’s always prudent to have that heightened level of suspicion.

And you did make one other comment that I think is poignant to point out and that is the increase in something called medical tourism which is people who are engaging in international travel for the principal or sole purpose of seeking healthcare in either direction and so there will be - I mean it’s not uncommon for large city hospitals in certain places to have an international population both here in the US and especially and increasingly abroad.

Coordinator:
Our next question comes from (Ellen Sheeman) - you line is open.

(Ellen Sheeman):
Yes for countries outside the immediate – those countries that have had MERS-CoV cases like Egypt, Israel - are those countries also places where we would consider patients to be at risk for this virus?

Dr. Susan Gerber:
Hi, this is Dr. Gerber - the Egypt case reported was in association with travel from Saudi Arabia. There haven’t been any cases reported from Israel, and in our case definition for patients under investigation, the countries of - that we identify are located within the Arabian Peninsula or neighboring countries, and we have a list on our website.

Coordinator:
Our next question is from (Theresa Holiday) - your line is open.

(Theresa Holiday):
Thank you. I just want to say that, I want to thank you all for sending out such great information. I’ve read everything and it’s very helpful and I know that’s a lot of work. My question is, if we have a patient that we suspect, a patient under investigation, and they meet those first three criteria so we move on to the testing, once we collect the specimens - do the specimens have to go from my hospital directly to the CDC or would I send them on to - I live in Illinois - so would I send it on to IDPH and then they would send it on? I don’t know the route for the specimens.

Dr. Susan Gerber:
The first thing - thank you for that question - this is Dr. Gerber. The first thing that you should consider if you suspect you may have a patient under investigation for MERS-CoV is to call your local or state health department.

(Theresa Holiday):
Yeah.

Dr. Susan Gerber:
That should be the first thing to consider, and at that point you can work on getting the specimens appropriately to the lab for testing. And most states in the US do have our assay and can run these tests in their lab.

(Theresa Holiday):
So they - I would work with my local and then it would be sent on to IDPH - is that correct?

Dr. Susan Gerber:
I can’t speak for the Illinois Department of Public Health, but...

(Theresa Holiday):
But that’s the route we would try and go to see if they would be able to handle the specimens, and if they cannot then they would go to the CDC.

Dr. Susan Gerber:
That is an option for states...

(Theresa Holiday):
Okay.

Dr. Susan Gerber:
...and we are happy to actually consult and test when it is needed so that is definitely – we are definately actively support all the states.

(Theresa Holiday):
Okay - thank you very much.

Leticia Davila:
Operator we will take one last quick question.

Coordinator:
Our last question is from (Paula Ovendeema) - your line is open.

(Paula Ovendeema):
Okay - thank you. Two questions so for the first question for the testing is there a case report form that would need to be complete and if there is one is it on the CDC website? And then the second is question is also for - do we know anything about whether or not MERS-CoV is contagious during the incubation period?

Dr. Susan Gerber:
Hi, this is Dr. Gerber - we have a patient under investigation form - it is a one-page form and we hope that it is filled out for all patients who are evaluated for MERS-CoV, and I believe it is on our website - I think so. And the second part of the question...

Dr. David Kuhar:
Contagious during the incubation period.

Dr. Susan Gerber:
During the - we don’t have any evidence yet on viral shedding or transmissibility data that really informs us about the incubation period or immediately before the onset of symptoms or even after the symptoms, which is why many of these types of recommendations we might make in general have to be in assessment with local and state health departments and based if more data comes in, will help to inform more solid general recommendations.

(Paula Ovendeema):
Thank you.

Leticia Davila:
Thank you. On behalf of COCA, I would like to thank everyone for joining us today with a special thank you to Dr. Gerber, Dr. Kuhar and Dr. Cetron. We invite you to communicate to presenters after the call. If you have additional questions for today’s presenters please email at coca@cdc.gov. Put May 6 COCA call in the subject line of your email and we will ensure that your question is forwarded to them for a response. Again that email address is coca@cdc.gov. The recording of this call and the transcript will be posted to the COCA website at emergency.cdc.gov/coca within the next few days.

There are no continuing education credits for this call. MERS-CoV resources for clinicians are available on the COCA call web page. Go to emergency.cdc.gov/coca click on COCA calls and then follow the links to the 2014 MERS-CoV call. To receive information on upcoming COCA Calls subscribe to COCA by sending an email to coca@cdc.gov and write subscribe in the subject line. All CDC launched a Facebook page for health partners. Like our page at http://www.facebook.com/cdchealthpartnersoutreach to receive COCA updates. Thank you again for being a part of today’s COCA call. Have a great day.

Coordinator:
This now concludes today’s conference - all lines may disconnect at this time. Thank you for your participation.

END

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