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Guidance for Health Care Workers and Health Sector Employers on Middle East Respiratory Syndrome Coronavirus

Last reviewed October 11, 2017
Last updated October 11, 2017

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 October 11, 2017:

  • The ministry has clarified and updated the case definition based on improved understanding of transmission purposes.

Case Definitions - Adapted from the Public Health Agency of Canada's National Case Definition

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 a travel history to or resided in Saudi Arabia within 14 days before onset of illness

OR

  • the person has travel history or resided in one or more of the other affected countries1 AND had any of the following associated risk factors:
    • the person had contact with a health care facility (i.e., as a patient, worker or visitor) in one of more of the other affected countries1 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) in one of more of the other affected countries 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 a travel history to or residence in Saudi Arabia or
    • who had contact with a health care facility (i.e., as a patient, worker or visitor)  or camel or camel products (e.g., raw milk or meat, secretions or excretions, including urine) in one or more of the other affected countries1.
  • The person has acute respiratory illness of any degree of severity and, 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.

Probable Case

A person with an acute respiratory illness of any degree of severity who had close contact2 within 14 days before onset of illness 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 Public Health Ontario Laboratory (PHOL) that is awaiting confirmation by the National Microbiological Laboratory (NML).

Confirmed Case

A person with laboratory confirmation7 of infection with the MERS-CoV virus

Case Definition Footnotes

  1. Saudi Arabia is experiencing continuing local transmission of MERS-CoV. Other affected countries in the Middle East with 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 had contact with a case of MERS-CoV, a health care facility (such as a patient, worker or visitor) or camels/ camel products (e.g. raw milk or meat, secretions or excretions, including urine). The risk of MERS-CoV infection for individuals from these other affected countries without exposure to a case of MERS CoV, a health care facility or camels/ camel products is extremely low.
  2. 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.

  3. 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.
  4. 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.
  5. Testing should be according to local guidance for management of community-acquired pneumonia. Examples of other aetiologies include Streptococcus pneumoniae, Haemophilus influenza type bb, Legionella pneumophila, other recognized primary bacterial pneumonias, influenza and respiratory syncytial virus.
  6. A laboratory diagnosis of MERS-CoV is unavailable if there is no possibility of acquiring samples for testing.
  7. 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.
  8. In Canada, laboratory confirmation of infection with the MERS-CoV virus is done by the NML. After the PHOL has identified a presumptive confirmed case, the sample will be sent to the NML for confirmation.

Screening

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 Additional Precautions (Contact, Droplet, Airborne) by health care workers at risk of exposure to a confirmed case, presumptive confirmed case, probable case or person under investigation (or PUI) and/or the patient's environment. These precautions include:

  • hand hygiene
  • 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, fit-tested, seal-checked N95 respirators and eye protection by health care workers when entering the same room as the patient or when transporting or caring for the patient

For more information on Routine Practices and Additional Precautions, health care workers 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.

Assessment

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 the case with the on-call medical microbiologist at PHOL.

Laboratory Testing

PHOL conducts laboratory testing for MERS-CoV. Health care workers should review PHOL's Test Information Sheet for MERS-CoV for more information on laboratory testing. As noted above, PHOL Customer Service Centre should be contacted if MERS-CoV testing is being considered (416-235-6556/ 1-877-604-4567).

Health care workers are encouraged to submit laboratory samples as soon as possible to PHOL.

Reporting

Health care workers should contact their public health unit to report a confirmed case, presumptive confirmed case, probable case or PUI.

Treatment

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:

These documents also outline occupational health & safety and infection prevention & control measures that may differ from those being recommended by the Ontario Ministry of Health and Long-Term Care – see Occupational Health & Safety and Infection Prevention & Control above for the recommended measures in Ontario.

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 for a confirmed, presumptive confirmed or probable case of MERS-CoV,, as well as PUIs who are close contacts of a presumptive confirmed, confirmed or probable case.

Further Information

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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