Background

Middle East respiratory syndrome (MERS) is a respiratory disease caused by a newly recognized coronavirus (MERS-CoV). It was first reported in 2012 in Saudi Arabia and is thus far linked to countries in or near the Arabian Peninsula (United Arab Emirates [UAE], Qatar, Oman, Jordan, Kuwait, Yemen, and Lebanon). As of May 2014, two cases had been reported in the United States, both in men who had recently returned from Saudi Arabia.

See 11 Travel Diseases to Consider Before and After the Trip, a Critical Images slideshow, to help identify and manage several infectious travel diseases.

Also, see the Ebola: Care, Recommendations, and Protecting Practitioners slideshow to review treatment, recommendations, and safeguards for healthcare personnel working with infectious diseases, as well as the Acute Respiratory Distress Syndrome: A Complex Clinical Condition slideshow for more information on ARDS, a condition characterized by acute respiratory failure, hypoxemia, and pulmonary edema.

MERS is typically characterized by cough, fever, and shortness of breath. Most individuals with confirmed MERS have developed acute respiratory illness, and, among the 536 cases reported through May 12, 2014, the mortality rate has been 30%. However, the number of cases and fatalities reported in Saudi Arabia has recently been revised following alleged underreporting. The updated total number of cases in that country has been increased to 688 from the previous count of 575, and the total number of deaths has been increased to 282 from 190, representing a mortality rate of more than 40%.

MERS-CoV has been shown to spread from person to person via close contact but without sustained community transmission. Potentially at-risk individuals include caregivers and close contacts of people with suspected or confirmed MERS-CoV infection. Transmission has occurred via close contact with infected persons, including from patients to healthcare personnel.

Laboratory testing for MERS-CoV is not routinely available, although polymerase chain reaction (PCR) for MERS-CoV is available at state health departments, the Centers for Disease Control and Prevention (CDC), and some international laboratories. Some commercial tests are available, but none has received US Food and Drug Administration (FDA) approval.

No vaccine currently exists for MERS, and no specific treatment has been recommended. Management is currently supportive. However, at least one group has recommended consideration of interferon alfa 2b plus ribavirin in the management of MERS-CoV cases because of the combination’s efficacy seen in rhesus macaques with MERS.

Travelers who have recently visited countries in or near the Arabian Peninsula are advised to contact their healthcare provider if they develop MERS symptoms (ie, fever, cough, shortness of breath) within 14 days of travel. Individuals who have been in recent contact with a symptomatic person who has recently traveled to the Arabian Peninsula should also be evaluated for MERS-CoV infection.

Because of an ongoing 2015 outbreak of MERS in South Korean healthcare facilities, the CDC has also recently advised clinicians to ask patients with serious respiratory problems whether they have recently been in a healthcare facility in South Korea to screen for MERS-CoV. A patient presenting with fever and pneumonia or acute respiratory distress syndrome should be evaluated for MERS if he or she had been a patient, worker, or visitor in a South Korean healthcare facility within 14 days of symptom onset.

In patients who meet these screening criteria, the CDC recommends evaluation for common causes of community-acquired pneumonia based on clinical presentation and epidemiologic and surveillance information. Testing for MERS-CoV and other respiratory pathogens can be performed concurrently. Results that confirm a different respiratory pathogen should not necessarily preclude testing for MERS-CoV.

If possible, the CDC recommends collection of multiple specimens from different sites at various times following the onset of symptoms. Infection-control measures should be used during collection using approved equipment and methods. Specimens should be handled, stored, and shipped following appropriate protocols.

Lower respiratory specimens are preferable. Oropharyngeal and nasopharyngeal specimens, in addition to serum and stool, are strongly recommended to increase diagnostic yield.

Collection of respiratory specimens should begin as soon as possible following symptoms onset; nonetheless, respiratory specimens should still be collected beyond this period if the patient remains symptomatic more than one week following symptom onset (particularly lower-respiratory specimens) since real-time reverse-transcription PCR (rRT-PCR) can still be used for detection.

Standard contact and airborne precautions are recommended for management of hospitalized patients with known or suspected MERS-CoV infection. The complete CDC guidance can be found on the CDC website (Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV ); a key recommendation includes placing the patient in contact and airborne isolation room as soon as possible. In addition, personal protective equipment for healthcare personnel, including gloves, gowns, eye protection (goggles or face shield), and respiratory protection that is at least as protective as fit-tested NIOSH-certified disposable N-95 filtering face piece respirator must be utilized.

For current CDC recommendations for healthcare professionals, see also Interim Guidance for Health Professionals.