Emerging infectious diseases continue to challenge emergency physicians and emergency department leaders.1 Building on prior work for management of patients under investigation for Ebola virus disease and measles, the identify-isolate-inform (3I) tool has been newly adapted to help emergency department personnel in the management of patients at risk for Middle East respiratory syndrome (MERS).2-6
Middle East Respiratory Syndrome
Initially described in Saudi Arabia in September 2012, MERS was later detected in other countries in the Arabian Peninsula and spread to Korea in May 2015. In late August 2015, a surge in cases detected in Riyadh, Saudi Arabia, brought the total to 100 patients in a little over one month, again raising concerns that the outbreak was not over. In fact, on a single day, the Saudi Ministry of Health reported seven new cases, with six deaths over a three-day period, all of them from Riyadh. While no sustained human-to-human transmission has been reported to date, at least 26 countries have reported MERS cases.
The vast majority of MERS cases outside of the Arabian Peninsula have been in travelers to the region, including two unlinked cases in Indiana and Florida in May 2014 in patients believed to have been infected while they functioned as health care workers in Saudi Arabia. Both patients were hospitalized and recovered. Nevertheless, as evidenced by reports from Saudi Arabia, disease transmission is occurring within health care facilities, and clinicians are at particularly high risk of contracting MERS from their infected patients—as was the case in the severe acute respiratory syndrome (SARS) epidemic. As of August 24, 2015, the World Health Organization reported 1,432 cases globally, with at least 507 deaths. The majority of cases have been reported from Saudi Arabia.
MERS presents as a nonspecific acute respiratory illness. Typically, patients have fever, cough, and shortness of breath. However, gastrointestinal symptoms can predominate and include nausea, vomiting, and diarrhea. Pneumonia, acute respiratory distress syndrome, and renal failure can develop in severe cases; mortality is reported at about 30 to 40 percent. Patients with underlying medical conditions are at greater risk for severe illness and death. While the typical incubation period is five to six days, the range can be two to 14 days and hence the recommendation for screening of exposure within 14 days prior to presentation.
While uncertainty remains about the exact mode of transmission, it’s likely MERS spreads like other coronaviruses, via respiratory secretions of an infected person. Close contact with a contagious person (or possibly with an infected dromedary camel) is thought to be necessary for spread of illness. Suspected MERS patients require airborne infection isolation, and health care workers must don N95 respirators or equivalent respiratory protection in addition to observing standard precautions.