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.

Clinical Presentation

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.

MERS Transmission

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.

The following groups are at risk of being infected and contagious:

• Travelers from the Arabian Peninsula
• Close contacts of an ill traveler from the Arabian Peninsula
• People who have been in a health care facility in the Republic of Korea
• Close contacts of a confirmed case of MERS

The MERS 3I Tool

With global travel opportunities, it is essential to assess for risk of exposure to transmissible infectious diseases for all patients presenting to the emergency department. With input from the ACEP Ebola Expert Panel and guidance from the Centers for Disease Control and Prevention, a simple algorithm was developed. This modified 3I tool is intended for use in management of patients under investigation for MERS.

First, an assessment of epidemiologic risk factors, including travel to countries with current cases and contact with patients with confirmed MERS within 14 days, is performed. Patients are then risk-stratified by type of exposure, coupled with symptoms of fever and respiratory illness. If criteria are met for MERS risk, patients must be immediately placed into airborne infection isolation. The final step is for the emergency practitioner to alert hospital infection control and the local public health department. The MERS 3I tool is a new addition to the armamentarium of frontline emergency workers that will facilitate rapid categorization and triggering of appropriate time-sensitive actions for patients presenting to the emergency department at risk for MERS.

References

1. Koenig KL, Schultz CH. The 2014 Ebola virus outbreak and other emerging infectious diseases. Accessed Sept. 1, 2015.
2. Koenig KL, Majestic C, Burns MJ. Ebola virus disease: essential public health principles for clinicians. West J Emerg Med. 2014;15:728-731.
3. Koenig KL. Identify, isolate, inform: a 3-pronged approach to management of public health emergencies. Disaster Med Public Health Prep. 2015;9:86-87.
4. Koenig KL, Burns MJ, Alassaf W. Identify-isolate-inform: a tool for initial detection and management of measles patients in the emergency department. West J Emerg Med. 2015;16:212-219.
5. Augustine JJ. Measles outbreak highlights the need for infectious disease containment protocols in the emergency department. ACEP Now, Feb. 12, 2015.
6. Koenig KL. Identify-isolate-inform: a modified tool for initial detection and management of Middle East respiratory syndrome patients in the emergency department. West J Emerg Med. 4, 2015. [epub ahead of print]

Dr. Koenig is director of the University of California, Irvine Center for Disaster Medical Sciences and professor of emergency medicine and public health at the UC Irvine School of Medicine.