Guidance for Health Care Workers and Health Sector Employers on Middle East respiratory syndrome coronavirus
|Last reviewed||February 11, 2016|
|Last updated||February 11, 2016|
This information is intended for use by health care workers and health sector employers in all settings.
What is New?
The following updates were made on February 11, 2016:
- The ministry has revised the MERS-CoV case definition for a person under investigation (PUI) to be more specific regarding travel history and exposures to health care settings and camels or camel products while in countries where MERS CoV is circulating.
Case Definitions - Adapted from the Public Health Agency of Canada's Interim Case Definition
Note that these case definitions are for surveillance purposes. They are not intended to replace clinical or public health practitioner judgment in individual patient assessment and management.
Person under Investigation
A person with an acute respiratory illness, which may include history of fever and new onset of (or exacerbation of chronic) cough or breathing difficulty with or without indications of pulmonary parenchymal disease (e.g., pneumonia or acute respiratory distress syndrome [ARDS]) based on clinical or radiological evidence of consolidation AND any of the following:
- the person has travel history or resided in Saudi Arabia within 14 days before onset of illness;
- the person has travel history or resided in other affected countries 1 within 14 days before onset of illness, AND had any of the following associated risk factors: the person had contact with a healthcare facility (i.e.: as a patient, worker or visitor) within the affected countries 1 within 14 days before onset of illness; or
- the person had contact with camel or camel products (e.g. raw milk or meat, secretions or excretions, including urine) within 14 days before onset of illness;
- The person had close contact2 within 14 days before onset of illness with a person with acute respiratory illness of any degree who had travel history to or residence in Saudi Arabia or other affected countries1 as defined above.
- A person with an acute respiratory illness of any degree of severity who, within 14 days before onset of illness, had close contact2 with a confirmed case, presumptive confirmed case, or probable case of MERS-CoV infection while the case was ill.
- The disease occurs as part of a cluster3 that occurs within a 14-day period, without regard to place of residence or history of travel, unless another aetiology has been identified4.
- The disease occurs in a health care worker who has been working in an environment where patients with severe acute respiratory illness are being cared for, particularly patients requiring intensive care, without regard to place of residence or history of travel, unless another aetiology has been identified4.
- The person develops an unexpectedly severe clinical course despite appropriate treatment, even if another aetiology has been identified, if that alternate aetiology does not fully explain the presentation or clinical course of the patient.
A person with an acute respiratory illness of any degree of severity who had close contact with a confirmed case or presumptive confirmed case and from whom laboratory diagnosis of MERS-CoV is unavailable5 or inconclusive6
Presumptive Confirmed Case
A person with a positive laboratory result of infection for MERS-CoV virus from the PHOL that is awaiting confirmation by the National Microbiological Laboratory
A person with laboratory confirmation7 of infection with the MERS-CoV virus
Case Definition Footnotes
- Saudi Arabia is currently experiencing continuing local transmission of MERS-CoV. Other affected countries in the Middle East with recent limited transmission among adults include Jordan, Oman, Qatar, the United Arab Emirates and Yemen. However, for these other countries, cases have almost been exclusively limited to adults who have had contact with a case of MERS-CoV, a healthcare facility (such as a patient, worker or visitor) OR who have had contact with camel or camel products (e.g. raw milk or meat, secretions or excretions, including urine). The risk of MERS-CoV infection for individuals from these other countries without healthcare or camel exposure is extremely low.
As this list of affected countries is subject to change, health care workers and health sector employers should review this footnote regularly for the latest information.
- Close contact is defined as anyone who provided care for the patient, including a health care worker or family member, or who had other similarly close physical contact , or anyone who stayed at the same place (e.g., lived with, visited) as a confirmed case, presumptive confirmed case or probable case while the case was ill.
- A cluster is defined as two or more persons with onset of symptoms within the same 14-day period and who are associated with a specific setting, such as a classroom, workplace, household, extended family, hospital, other residential institution, military barracks or recreational camp.
- Testing should be according to local guidance for management of community-acquired pneumonia. Examples of other aetiologies include Streptococcus pneumoniae, Haemophilus influenza type B, Legionella pneumophila, other recognized primary bacterial pneumonias, influenza and respiratory syncytial virus.
- A laboratory diagnosis of MERS-CoV is unavailable if there is no possibility of acquiring samples for testing.
- Inconclusive is defined as a positive test on a single target, a positive test with an assay that has limited performance data available, or a negative test on an inadequate specimen.
- In Canada, laboratory confirmation of infection with the MERS-CoV virus is done by the National Microbiology Laboratory (NML). After the PHOL has identified a presumptive confirmed case, the sample will be sent to the NML for confirmation.
The Ministry of Health and Long-Term Care (ministry) recommends that health care settings continue to implement routine case finding/ surveillance methods to identify individuals with acute respiratory infection, as per the Provincial Infectious Disease Advisory Committee's (PIDAC's) Annex B: Prevention of Transmission of Acute Respiratory Infection in all Health Care Settings [PDF].
Depending on the type of health setting, routine case finding/surveillance methods include passive and/or active methods.
Health care workers should follow appropriate occupational health & safety and infection prevention & control measures for individuals who fail the passive and/or active screening process.
Occupational Health & Safety and Infection Prevention & Control
The ministry recommends the use of Routine Practices and Contact, Droplet and Airborne Precautions, by health care workers at risk of exposure to a confirmed case, presumptive confirmed case, probable case and PUIs and/ or the patient's environment. These precautions include:
- use of airborne infection isolation rooms when possible
- masking the patient with a surgical mask when outside of an airborne infection isolation room
- use of gloves, gowns and fit-tested, seal-checked N95 respirators and eye protection by health care workers when entering the same room as, transporting or caring for the patient
For more information on Routine Practices and Contact, Droplet and Airborne Precautions , health care worker should refer to (PIDAC's) Routine Practices and Additional Precautions in All Health Care Settings [PDF] and Annex B: Prevention of Transmission of Acute Respiratory Infection in all Health Care Settings [PDF].
The use of Airborne Precautions is a higher level of precaution than is being recommended by the Public Health Agency of Canada or the World Health Organization (WHO), or that is normally recommended for coronaviruses. The ministry is recommending that health care workers apply Airborne Precautions based on the application of the precautionary principle to this novel virus for which little information about transmission and clinical severity is available.
Health care workers should assess patients who have acute respiratory infection to determine if they meet any of the criteria of the MERS-CoV PUI case definition in addition to considering/testing for other common respiratory pathogens.
Health care workers considering the need to test a patient for MERS-CoV should contact PHOL's Customer Service Centre at 416-235-6556/ 1-877-604-4567 for advice and support. PHOL may approve testing for MERS-CoV in patients who do not fit all criteria in the PUI case definition. Requesting physicians should discuss with the on-call medical microbiologist at PHOL.
Laboratory testing for MERS-CoV is conducted by the PHOL. Laboratory testing information is available on PHOL's Test Information Sheet for MERS-CoV.
Health care workers must contact their public health unit to report a confirmed case, presumptive confirmed case, probable case and PUI.
Medical care is supportive; there are no specific treatments targeting this virus. Health care workers should manage patients with MERS-CoV based on their clinical presentation. Patients who do not require admission for clinical care may be discharged with instructions to isolate; this includes PUIs who are awaiting MERS-CoV test results. For patients who are discharged, health care workers should work with their public health unit to make arrangements for clinical and public health follow-up.
The ministry has developed a fact sheet entitled Preventing MERS-CoV from Spreading to Others in Homes and Communities to support health care workers to provide guidance and information for PUIs, probable cases, and confirmed cases who are discharged to be cared for at home. The fact sheet is also available in the following languages: French, Korean, Arabic, German, Italian, Portuguese, Punjabi, Spanish, Tagalog, Urdu, Tamil, Farsi, Hindi, Thai, Chinese (Traditional) and Chinese (Simplified).
For further information on treatment, health care workers may refer to the following documents:
- WHO's Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do
- Public Health England's Treatment of MERS-CoV: Information for Clinicians (developed in collaboration with the International Severe Acute Respiratory & Emerging Infection Consortium)
Note that recommended infection prevention & control measures in these documents may differ from those being recommended in Ontario – see Occupational Health & Safety and Infection Prevention & Control above for more information.
Case and Contact Management
Public health units may refer to Public health management of cases and contacts of Middle East respiratory syndrome coronavirus in Ontario (PDF) for guidance on conducting case and contact management of a confirmed, presumptive confirmed or probable case of MERS-CoV in Ontario.
- PIDAC's Tools for Preparedness: Triage, Screening and Patient Management for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infections in Acute Care Settings [PDF]
- The Ministry of Labour's Health and Community Care webpage
- The ministry's Frequently Asked Questions on MERS-CoV
For more information, call the ministry's Health Care Provider Hotline at 1-866-212-2272.
This information does not relieve employers from their legislated obligations.
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