MERS From 2012 to 21 July 2017,

2,040 reported laboratory-confirmed cases

712 deaths in 27 countries

A single imported case of MERS in South Korea, identified A single imported case of MERS in South Korea, identified on 20 May 2015,

150 laboratory-confirmed cases,

15 deaths

within 26 days, mainly among patients, visitors & healthcare personnel

Scenario On 17 June, the response team received a notification

that there was a suspected case of MERS, 60 year-old male from country O (risk area of MERS).

The case travelled with 2 sons and 1 nephew. The case travelled with 2 sons and 1 nephew.

He went to Hospital B with CC of CHF.

Scenario Doctor suspected pneumonia and admitted him to negative

pressure unit (NPU). Nasopharyngeal swabs were collected

1st time: UpE undetectable, Orf 1A undetectable

2nd time: UpE undetectable, Orf 1A undetectable 2nd time: UpE undetectable, Orf 1A undetectable

Patient was transfer red out of NPU

You are the rapid response team, what would you do? Investigate or not?

Any actions required?

Team decide to investigate this case What are the objectives of the investigation?

What should be done next? What should be done next?

At outbreak begins

• Prepare for Field Work : Rapid Response Team

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•Verify diagnosis and confirm outbreak

Prepare for Field Work : Rapid Response Team

A. Administration and authorization: inform the concerned

B. Brief and mobilize multi-disciplinary team: define tasks and

person who be in-charge

C. Consultation: clinician, lab, stakeholders, etc.

D. Documentation for knowledge: literature, CPG,

questionnaires, and preliminary information

E. Equipment, material, medical and non-medical supplies,

e.g. PPE, specimen collection & transport,

communication

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Verify diagnosis & confirm outbreak

Differential diagnosis?Review clinical symptoms from pt., relatives,

HCWs

Verify diagnosis? Lab confirmed ? If not, appropriated lab specimen?

Confirm outbreak?

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During the team preparing, the hospital B notified that pt.’s condition deteriorated and was intubated.

The team requested sputum suctioned from ET-T for MERS-CoV for Dx confirmation.CoV for Dx confirmation.

What would you do when arrived the hospital B?

Interview?, contents?

Will you collect specimens from relatives?

4-7/6: Dx ACS,

10/6: dry cough

13-14/6: dry

14/6: crepitation, abnormal CXR in RML, RLL

15/6: travelled to ThailandTaxi1: airport to hotel YTaxi2: hotel Y to hospital B

4-7/6: Dx ACS, admitted, no fever, dry cough,

13-14/6: dry cough, no fever

Country O Thailand

sputum suctioned from ET-T:

UpE detectable, Orf 1A detectable

Pt. was immediately transferred back to NPU

(pt was in ICU for 6 hrs) (pt was in ICU for 6 hrs)

Please evaluate the present situation

What should be done, next?

Steps of an outbreak investigation

1. Prepare for Field Work : Rapid Response Team2. Confirm outbreak and diagnosis3. Define case and start case-finding

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3. Define case and start case-finding4. Descriptive data collection and analysis5. Develop hypothesis6. Analytical studies to test hypotheses7. Special studies (e.g. environmental, lab study)8. Communicate the conclusion and recommend

control measures9. Follow-up the control implementations

The 1st imported confirmed MERS in Thailand was found

Active case finding was done

Contacts: high risk, low risk groups

EOC was activated EOC was activated

The objectives were

Categorized contacts as high or low risk group in order to quarantine

Specimen collection

Inform the concerned with administration and authorization: policy to quarantine

Please list the group of contacts that we should evaluate

What evidences we should look for the clue of What evidences we should look for the clue of exposure to the confirmed case?

place Group of contacts evidences

Country O Relatives travelled with pt. interview

Contacts in country O within 1m radius

Contact country O

airplane Passenger esp. 2 rows in the front and back

Boarding pass, interview, seat plan, immigration documentsimmigration documents

Airline crews Flight documents

airport Ground staff CCTV, interview

Immigration officers CCTV, interview

transportation

Taxi driver 1-2 Traffic control CCTV, hotel CCTV interview,

Hotel Hotel staff CCTV, interview

Hospital B HCWs within 1m radius CCTV, interview

How you define contacts as High or Low risk group?

Contacts A high-risk close-contact

person who was within 1 m of contact with the index case while the patient was symptomatic

regardless of duration of contact.

Airline passengers seated in the two rows surrounding the index Airline passengers seated in the two rows surrounding the index case’s seat

A low-risk contact person who had been > 1 m in contact with the patient while the

patient was symptomatic,

A non-contact no evidence of direct contact with the pt. or

were not likely to be in contact with respiratory droplets

What actions for each High or Low risk contact group?

What would you do with the HCWs and other patients in ICU?

Quarantined 3 HCWs who directly contacted with pt.

Halted the patient transfer in/out ICU

Specimen collection

Happy ending All specimen testing negative

Pt. clinical improved and D/C from hospital after negative results for 3 times, travelled back with relatives