Middle East Respiratory Syndrome (MERS) 

Updated: May 10, 2019
Author: Sandra G Gompf, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD 

Overview

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. Laboratory-confirmed MERS has now been identified in Bahrain, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates (UAE), and Yemen.

A large MERS outbreak occurred in the Republic of South Korea linked to a traveler from the Arabian Peninsula in 2015. Travel-associated cases have been identified in Algeria, Austria, China, Egypt, France, Germany, Greece, Italy, Malaysia, Netherlands, Philippines, Republic of Korea, Thailand, Tunisia, Turkey, United Kingdom (UK), and United States (US). Only two cases have been reported in the United States, both in men who had recently returned from Saudi Arabia. Only two of over 800 cases screened have tested positive for MERS-CoV since 2012.[1, 2]

MERS is considered an international threat to public health. CDC has published guidance for health departments and healthcare infection-control programs for investigating potential cases of MERS and preventing its spread. Tools and guidance for recognizing and reporting ill travelers have been issued to US flight crews, Emergency Medical Service (EMS) units at airports, and US Customs and Border Protection (CPB) officers. CDC maintains ongoing close partnerships in the international public health community to monitor risk and to inform US preventive measures.[2]

Vero cells infected with Middle East respiratory s Vero cells infected with Middle East respiratory syndrome coronavirus (MERS-CoV). Image courtesy of the Centers for Disease Control and Prevention (Jennifer L. Harcourt).

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.

Most individuals with confirmed MERS have developed acute respiratory illness. Illness may be complicated by pneumonitis and multiorgan failure Over 800 MERS-CoV–associated deaths have occurred since September 2012.[3] MERS-CoV has been shown to spread from person to person via close contact but without sustained community transmission. Transmission has occurred via close contact with infected persons, including from patients to healthcare personnel. Potentially at-risk individuals include caregivers and close contacts of people with suspected or confirmed MERS-CoV infection.[4]

Laboratory testing for MERS-CoV is not routinely available, although polymerase chain reaction (PCR) for MERS-CoV is available via state health departments, CDC, and some international laboratories. Some commercial tests are available, but none has received approval from the U.S. Food and Drug Administration (FDA).[2]

No vaccine currently exists for MERS, and no specific treatment has been recommended. Management is currently supportive.[5] 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.[6]

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).

Etiology

Coronaviruses are the largest of all RNA viruses, with positive-sense single-stranded RNA genomes of 26-32 kb. They are classified into 4 phylogenetic subgroups: alphacoronavirus, betacoronavirus, gammacoronavirus, and deltacoronavirus.[7] SARS-CoV belongs to the lineage B betacoronavirus and was responsible for the 2002-2003 severe acute respiratory syndrome (SARS) outbreaks, which first highlighted the potentially high pathogenicity of human coronaviruses.

MERS-CoV is a recently discovered betacoronavirus of lineage C that was first reported in Saudi Arabia in 2012. The exact origin of this novel coronavirus is still unknown. MERS-CoV is closely related to two coronaviruses of the same lineage found in bats, which may indeed be  its wild reservoir.[8] However, it is also found in dromedary (single-humped) camels, and domesticated herds have been a principal link to zoonotic infection in humans.[9, 10, 11, 12]

The specific transmission mechanisms between humans and the possible source animals are unknown,[5] and, although human-to-human transmission has been demonstrated, the chain of transmission is not self-sustaining, making early identification and isolation a feasible strategy to limit the spread of the virus. The virus tends not to spread beyond one individual to others.[13]

Pathophysiology

One of the most important cells of the innate immune system is the macrophage. Its function is to eliminate pathogens, to present antigens to T cells, to produce cytokines and chemokines to maintain homeostasis, and to modulate the immune response in tissues.[14]

Compared with severe acute respiratory syndrome coronavirus (SARS-Cov), MERS-CoV can establish infection in monocyte-derived macrophages (MDMs) and macrophages. The virus induces release of proinflammatory cytokines, leading to severe inflammation and tissue damage, which may manifest clinically as severe pneumonia and respiratory failure.[15] Vascular endothelial cells located in the pulmonary interstitium may also be infected by MERS-CoV, and, because MERS-CoV receptor DPP4 is expressed in different human cells and tissues, dissemination of the infection may occur.[15] This may explain the increased severity and higher fatality rate compared with SARS-CoV infection.

Interestingly, lymphopenia has been noted in most patients infected with MERS-CoV, as was noted in SARS infections. This is due to cytokine-induced immune cell sequestration and release and induction of monocyte chemotactic protein-1 (MCP-1) and interferon-gamma-inducible protein-10 (IP-10), which suppresses proliferation of human myeloid progenitor cells.[16]

Epidemiology

Since 2012, 2,374 laboratory-confirmed cases of infection with MERS-CoV have been reported to the World Health Organization (WHO), including at least 823 related deaths.[3]

Twenty-seven countries have reported MERS cases. On the Arabian Peninsula, countries include Bahrain, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates (UAE), and Yemen. Other countries reporting travel-associated MERS include Algeria, Austria, China, Egypt, France, Germany, Greece, Italy, Malaysia, Netherlands, Philippines, Republic of Korea, Thailand, Tunisia, Turkey, United Kingdom (UK), and the United States. The vast majority of these cases have so far occurred in the Kingdom of Saudi Arabia.[17]

The largest MERS outbreak outside of Saudi Arabia occurred in 2015 in the Republic of Korea. The outbreak involved 186 confirmed cases and caused 36 deaths. The outbreak sparked quarantine of more than 5,000 individuals and the closure of 2,000 schools before ending.[18] The index case was a 35-year-old man exposed to a laboratory-confirmed case on May 27 while visiting Bahrain. He visited four hospitals before being admitted and testing positive for MERS-CoV on June 7. He recovered and was discharged on October 1 after confirmation of two negative test results.[3, 19] Most of the subsequent cases were related to healthcare-associated exposures of those caring for infected patients, and most deaths occurred in those already hospitalized, with a case fatality rate of only 10%. No cases were found to be community-acquired. South Korean officials enacted an aggressive campaign of isolating contacts in the community and hospitals for 14 days after exposure, which likely contained the outbreak to nosocomial settings.[20]

The first case of MERS in the United States was reported to the CDC by the Indiana State Department of Health on May 1, 2014, and confirmed by the CDC on May 2. The patient was a male who lived and worked in Saudi Arabia as a healthcare provider in a facility that had patients infected with MERS. He became ill around April 18, traveled by commercial airline from Saudi Arabia to Chicago, and then traveled by bus to Indiana. His initial symptoms included low-grade fever, myalgias, and rhinorrhea that later progressed to dyspnea and nonproductive cough. Chest radiography and CT scanning revealed bilateral infiltrates. The patient recovered uneventfully, and no secondary cases were reported.[1]

The second imported case was reported to the CDC by the Florida Department of Health on May 11, 2014. The patient was a healthcare worker who resided and worked in Saudi Arabia and had contact with a patient infected with MERS-CoV prior to presentation. He traveled by commercial airlines from Saudi Arabia to the United Kingdom, the United Kingdom to Boston, Boston to Atlanta, and finally from Atlanta to Orlando, where he was visiting family. His initial symptoms included myalgias, chills, and fever without cough. Because of persistent symptoms, he sought medical attention, and, soon after admission, he developed cough. Thoracic CT scans showed patchy nodular infiltrates bilaterally without mediastinal lymphadenopathy. Two healthcare workers developed a respiratory illness within the incubation period after they were exposed to the patient, but PCR testing of both showed negative results. The rest of the healthcare workers who were potentially in contact with the patient were furloughed, and none tested positive for MERS-CoV.[2, 1]

The virus is not readily transmissible between humans, requiring close contact for prolonged periods with an acutely ill individual. Close contact is defined by prolonged presence within 6 feet (2 meters) of the infected individual, such as during household contact or provision of health care.

In experiments controlling for temperature and relative humidity, tissue infectious quantities of MERS-CoV have been found to survive on surfaces for up to 48 hours under conditions that might approximate most air-conditioned indoor environments; higher temperatures and humidity reduced viability. Aerosolized virus remained most viable at lower relative humidities. These data and the frequent association of hospital visitation or healthcare-associated contact with infection suggest a significant role for inhalation and fomites. Association of infection with household contact appears low.[21, 22] Cough or sneezing and performance of aerosol-generating procedures such as intubation or bronchoscopy without respiratory droplet precautions increases the risk of exposure to infectious respiratory secretions. Extrapolating from other coronaviruses and experience during epidemics, transmission requires direct inhalation of respiratory droplets or contact with mucosa of respiratory secretions. The latter may be indirect, by contact with contaminated surfaces or fomites.[23, 24]

Specific mechanisms for transmission from animals is unclear but appear to involve contact with dromedary camels or their urine, as well as consumption of their undercooked meat or unpasteurized dairy products.[10, 23] Experimental studies have demonstrated that MERS-CoV inoculated into dromedary, cow, and goat milk remains stable and viable for up to 72 hours.[25] While MERS-CoV antibodies have been found in dromedary camels in the Middle East, the virus has not been detected in camel milk, nor have camels outside of the Arabian Peninsula been found to have antibodies to MERS–CoV. In one case of a man who died of MERS in Saudi Arabia, his camel herd was serially tested for MERS–CoV. Of samples, including nasal secretions, urine, milk, blood, and rectal swabs, the virus was detected only in nasal swabs for a transient period.[26] An outbreak investigation linked dromedary camels from a farm in Qatar to two human cases of infection in October 2013. MERS-CoV was virologically confirmed in nose swabs from 3 camels by 3 independent RT-PCR and sequencing assays.[27]

Prognosis

Many individuals with confirmed MERS have developed severe acute respiratory illness, and some have developed multiorgan dysfunction. The case fatality rate is approximately 30%-40% and may depend on the underlying health of the individual. Hospital-acquired infection has accounted for the highest number of deaths. Associated comorbidities, including end-stage renal disease on hemodialysis, diabetes, and chronic cardiopulmonary disease, have been associated with increased mortality rates. Delayed diagnosis and supportive care may also play a role. In the second largest outbreak in Korea, most cases involved limited transmission to presumably healthy healthcare workers, and none in the general community. The overall mortality rate was only 10%.[2, 19, 20]

Patient Education

Thus far, the global experience with MERS-CoV substantiates a very low risk to the general population. The US population is not considered to be at risk in the absence of close contact with individuals infected with MERS-CoV or travel to countries where the infection is actively occurring.

CDC issues travel notices when MERS is reported, with enhanced precautions for travelers who plan to work in healthcare settings in involved countries and in or near the Arabian Peninsula.[4] Travelers to an affected region who develop fever, cough, shortness of breath, or myalgias during their trip or within 14 days after returning to the United States are strongly encouraged to seek medical attention.[4]

The CDC advises that people observe the following tips to help prevent respiratory illnesses:

  • Wash hands often with soap and water for 20 seconds; if water and soap are not available, use an alcohol-based hand sanitizer.
  • Practice respiratory etiquette. Cover nose and mouth with a tissue or the inner elbow when coughing or sneezing.
  • Avoid touching eyes, nose, and mouth with unwashed hands.
  • Avoid close contact with sick individuals, such as kissing, sharing cups, or sharing eating utensils.
  • Clean and disinfect frequently touched surfaces, such as toys and doorknobs.
 

Presentation

History

The median incubation period of MERS infection is 5.2 days,[28] but periods of up to 12 days have been described,[29] thus ranging 4-14 days. Clinical manifestation is indistinguishable from other common respiratory viruses and may range from no symptoms to rapidly progressive multiorgan failure and death. The median time from onset to hospitalization is 4 days, with critically ill patients requiring intensive care within a median of 5 days from onset.

A high index of suspicion is necessary to suspect MERS, and a travel and exposure history is essential to the diagnosis. Keys to the case definition of MERS is a history of residence or travel in the Arabian Peninsula, in countries where MERS-CoV is known to be circulating in dromedary camels, or where human infections have recently occurred and exposure within the incubation period of 14 days.[30]

Upon suspicion of MERS, the patient should be placed in an airborne infection isolation room (AIIR) with a minimum of 12 air exchanges per hour, and personnel protection equipment (PEP) appropriate for contact and airborne precautions (gown, gloves, goggles, and N-95 respirator mask or powered air purifier respirator [PAPR]) should be used. Care should be taken to remove PEP without contact with contaminated outer surfaces.[31]

Predictors of more severe disease and higher risk of mortality include hospital-acquired infection, older age, immune disorders, and comorbidities including diabetes, end-stage renal disease, malignancy, and chronic cardiac and pulmonary conditions.

The initial presentation of MERS includes flulike symptoms, including fever, chills, rhinorrhea, fatigue, and myalgias. Respiratory symptoms, including cough and dyspnea, may become prominent later in the course. Pneumonitis is common. Gastrointestinal symptoms including anorexia, nausea, diarrhea, and abdominal pain have been reported.[32, 3]

Physical Examination

Physical examination findings associated with MERS-CoV infection are similar to those presenting with any flulike illness, including the following:

  • Fever
  • Rhinorrhea, mostly clear
  • Pulmonary findings, including hypoxemia, rhonchi, and rales (some patients may have a normal auscultation)
  • Tachycardia
  • Hypotension may occur with severe illness, reflecting systemic inflammatory response syndrome

Complications

In more severe cases of MERS, patients who develop pneumonitis and acute respiratory failure develop severe hypoxemia and require mechanical ventilation and possibly oxygen rescue therapy such as extracorporeal membrane oxygenation (ECMO). Vasopressor support and renal replacement therapy are often also required.[33]

 

DDx

Diagnostic Considerations

Patients who present with fevers, chills, myalgias, rhinorrhea, and pneumonia or who develop acute respiratory distress syndrome and have a history of travel to countries in or near the Arabian Peninsula within the past 14 days should be evaluated for Middle East respiratory syndrome (MERS) coronavirus (MERS-CoV) infection. Also, patients who have had close contact with a symptomatic traveler from this region or close contact with a confirmed or probable case should be evaluated for MERS-CoV infection.

In addition, 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.[32]

Clinical overlap may be seen with other viruses that manifest with flulike symptoms, and a proper clinical, epidemiological, and diagnostic evaluation should be performed.

Differentials

Influenza virus infection

Parainfluenza virus infection

Respiratory syncytial virus (RSV) infection

Adenovirus infection

Rhinovirus infection

Infection with other coronaviruses, including HC0V-OC43 and HCoV-229E, organisms responsible for the common cold

Metapneumovirus infection

Acute respiratory distress syndrome

Community-acquired pneumonia

Brucellosis

 

Workup

Approach Considerations

The CDC recommends collecting multiple specimens from different sites and times in suspected cases of Middle East respiratory syndrome (MERS), including nasopharyngeal and oropharyngeal swabs, sputum, serum, and stool/rectal swabs after symptom onset.

Evidence shows that lower respiratory tract specimens such as bronchoalveolar lavage (BAL), sputum, and tracheal aspirates contain the highest viral loads, and these are recommended. Some cases, including the second US case, have been confirmed only in sputum after negative or equivocal results on PCR for MERS-CoV in nasopharyngeal and oropharyngeal specimens.

The local health department should be notified immediately if a patient is suspected of having MERS-CoV infection. Proper personal protective precautions should be used by personnel collecting specimens (ie, gloves, eye protection, gowns, and respiratory protection with N-95 masks).

Real-Time Reverse-Transcriptase Polymerase Chain Reaction

The recommended algorithm for detection of MERS-CoV includes testing using rRT-PCR. Three assays have been developed. One assay targeting upstream of the E protein gene (upE) is recommended for screening. The other two assays target the open reading frame 1b (ORF 1b) and the open reading frame 1a (ORF 1a). The ORF 1a is more sensitive and considered equivalent to upE versus the ORF 1b assay.[3]

There are two target sites on the novel coronavirus genome identified that can be sequenced; these are located in the RNA-dependent RNA polymerase (RdRp) and N genes.[34]

To consider a case as laboratory confirmed, one of the following criteria must be met: (1) a positive PCR result for at least 2 different specific targets on the MERS-CoV genome or (2) one positive PCR result for a specific target on the MERS-CoV genome and an additional different PCR product sequenced confirming known sequences of MERS-CoV.[3]

The diagnostic algorithm for a case under investigation is as follows:

  • upE-specific rRT-PCR: if positive, confirm with ORF 1a rRT-PCR assay, and, if positive, case is confirmed
  • upE-specific rRT-PCR: if positive, confirm with one sequenced of the 2 target sites (RdRp or N assay), and, if positive, case is confirmed

A case with a positive PCR result for only one specific target in a patient with a history of possible exposure and compatible clinical presentation is considered probable.

False-negative results can occur if a poor-quality specimen is used, if the specimen was collected either late or very early in the illness, or if the specimen was not handled and shipped properly.[3]

The CDC Novel Coronavirus 2012 Real-time RT-PCR Assay (NCV-2012 rRT-PCR) is a qualitative, real-time (TaqMan®) RT-PCR developed in the United States that screens with upE rRT-PCR and confirms with N2 assay.[35]

On June 5, 2013, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for CDC’s 2012 real-time reverse transcription–PCR assay to detect MERS-CoV in clinical respiratory, serum, and stool specimens. CDC has distributed the assay to qualified laboratories in the United States and internationally. Most US state laboratories are thus able to test for suspected MERS-CoV infection with the rRT-PCR assay.[36, 37, 35]

Serology

Serologic testing for MERS-CoV is available as a research/surveillance test from the CDC; it is not considered a diagnostic test but may offer valuable epidemiologic data. It must be ordered in consultation and with approval of CDC via the EOC.

The serum specimens should be collected during the acute stage of the disease and repeated during the convalescence phase (>3 weeks after the initial sample was collected). This serologic test is available from the CDC and requires consultation and approval, since it is only for research or surveillance purposes.

The CDC performs a 2-stage procedure. First, serum is screened with enzyme-linked immunosorbent assays (ELISA) for nucleocapsid (N) and spike (S) proteins. If either is positive, confirmatory microneutralization testing is performed for neutralizing antibodies. A positive ELISA result and positive microneutralization test result is considered positive.

Further investigation is needed it to determine the sensitivity and specificity of these assays.[38]

Laboratory Studies

Laboratory findings at presentation may include leukopenia, lymphopenia, thrombocytopenia, and elevated lactate dehydrogenase levels. These are most likely with increasing severity of illness. Critically ill patients may develop acute renal failure requiring hemodialysis or continuous renal replacement therapy.[32]

Co-infection with other community-acquired viruses and bacteria have been described.[32]

Upon suspicion of MERS, clinicians in the United States should contact the CDC Emergency Operations Center (EOC) (770-488-7100; 24 hours/day, 7 days/week) for consultation.

As long as the patient remains symptomatic, specimens should be collected from nasopharynx, lower respiratory (bronchoalveolar lavage), and blood for CDC MERS rRT-PCR testing, even if more than 14 days from onset of illness. Specimens may be refrigerated at 3-8°C but should be frozen at -70°C if held longer than 72 hours. They are then shipped on dry ice.

Prior to collection of any laboratory specimens in suspected MERS cases, the laboratory should be notified of the possibility so that appropriate laboratory precautions are taken in processing them for shipping.

Specimen requirements for rRT-PCR are as follows:[37]

  • Bronchoalveolar lavage: 2-3 mL in a sterile, leak-proof, screw-cap sputum collection cup
  • Deep sputum specimen: After rinsing the mouth with water, expectorated directly into a sterile, leak-proof, screw-cap sputum collection cup
  • Nasopharyngeal swab and oropharyngeal swab (NP/OP swab) (synthetic fiber swab with plastic shaft only): Both swabs may be placed into the same sterile tube containing viral transport media.
  • Blood: 1 tube (5-10 mL) of whole blood in a serum separator tube

Other types of specimens, such as stool or urine, may harbor the virus for up to 6 weeks. They are not recommended for diagnostic testing but may have epidemiologic value.[39]

Imaging Studies

The clinical presentation of MERS overlaps with that of other viral and bacterial syndromes; this is also true for radiographic findings.

Chest imaging findings are abnormal in more than 80% of MERS cases. Ground-glass opacity (GGO) is found in over 60% of chest radiographs, with about 20% incidence of consolidation. Some infiltrates may be nodular.

Early findings occur in the peripheral mid-lung and lower-lung zones and are often unilateral. As illness progresses in severity, patchy infiltrates may spread to involve upper lung zones and may reflect noncardiac pulmonary edema due to ARDS.

Cavitation may occur early owing to a concurrent bacterial or other process. It may also appear 2-3 weeks into severe illness, along with other features of ARDS.

Pleural effusion, a notable feature that distinguishes MERS from other respiratory viral infections, occurs within one week of onset in about a third of cases. It may also predict higher mortality risk and poor outcome.[40]

Procedures

Procedures may include the following:

  • Mechanical intubation
  • Bronchoscopy with bronchoalveolar lavage
  • Renal replacement therapy or hemodialysis
  • Extracorporeal membrane oxygenation
 

Treatment

Approach Considerations

Rapid development of effective therapeutic options is a high priority since no antivirals are approved for the treatment of coronavirus infection nor vaccines available for prevention. Management of Middle East respiratory syndrome (MERS) coronavirus (MERS-CoV) infection is supportive; this includes hydration, antipyretic, analgesics, respiratory support, and antibiotics if needed for bacterial superinfection.

Experience during the SARS outbreak showed inconsistent results when antiviral therapy was used. One randomized trial compared ribavirin versus interferon1 alpha in SARS and showed no advantage of ribavirin over interferon.[41]

A recent study demonstrated activity of mycophenolic acid against the novel MERS-CoV; its potent in vitro activity may allow it to be used as monotherapy.[42]

Ribavirin and interferon alfa have synergistic in vitro effects against the virus, but their role (if any) in the treatment of MERS remains unknown.

A small observational study of 5 patients with MERS-CoV infection receiving ribavirin in combination with interferon alfa 2b in Saudi Arabia failed to show any benefit. These patients were all critically ill and on mechanical ventilation, and the median time from admission to therapy was 19 days, perhaps too late to demonstrate any benefit.

Similarly, Morra et al (2018), in a systematic review and meta-analysis, found that ribavirin plus interferon did not improve survival rates over supportive treatment alone.[43]

Consultations

Upon suspicion of MERS, the patient should be placed in an airborne infection isolation room (AIIR) with a minimum of 12 air exchanges per hour, and personnel protection equipment (PEP) appropriate for contact and airborne precautions (gown, gloves, goggles, and N-95 respirator mask or powered air purifier respirator [PAPR]) should be used. Care should be taken to remove PEP without contact with contaminated outer surfaces.[31]

Infection control and the local Health department should be notified immediately if a case of MERS-CoV infection is suspected.

Consultation with an infectious disease specialist and the CDC EOC is strongly recommended. The CDC EOC is available 24 hours a day, 7 days a week (770-488-7100).

Consultation with a pulmonologist/critical care specialist should be considered if severe respiratory complications develop, as well as a nephrologist if renal failure ensues.

Medical Care

Medical care is supportive and depends on severity of illness.

Prevention

No MERS-CoV vaccine is commercially available. Prevention of infection in areas where MERS-CoV is being actively transmitted requires avoidance of potentially infectious secretions and careful attention to hand and respiratory hygiene.

Persons planning travel to areas in and around the Arabian Peninsula can check for travel advisories in the regions they plan to visit. Updated information can be found at the U.S. State Department Travel Advisories and CDC Travel Health Notices.

All travelers should practice good hygiene while abroad, including washing hands frequently (especially after contact with animals), avoiding sick animals, and avoiding consumption of unpasteurized or undercooked animal products. WHO offers specific advice at Frequently Asked Questions on MERS-CoV.

CDC Travel and the U.S. State Department - International Travel offer excellent health and safety guidance for travelers with various travel plans and personal needs.

People suspected or confirmed to have MERS need not be hospitalized unless seriously ill. Recommendations for infected individuals and their caregivers include the following:[32]

  • Stay at home and away from public places other than necessary to seek medical care. Call ahead to the healthcare facility and advise the staff of suspected or documented MERS when medical care is needed.
  • Restrict visitors and nonessential household members, especially those who are older or immunocompromised.
  • Wear a disposable surgical face mask when around other people or in public and replace it every few hours.
  • Avoid touching the face whenever possible. Wash hands frequently with soap and water or use an alcohol-base hand sanitizer often.
  • Keep separate from others in the home whenever possible. Stay in a separate room, use a separate bathroom, and keep separate eating and drinking utensils, towels, clothing, bedding, and other items. These should be washed with soap and water or sanitized with a surface disinfectant known to kill coronaviruses.
  • Wear disposable gloves when handling potentially contaminated surfaces or objects, including laundry and other potential fomites. All disposable contaminated items may be discarded in regular household trash bags and trash collection. Bags should be well tied.
  • Wipe all “high-touch” surfaces (countertops, doorknobs, bath fixtures, toilets, phones, keyboards, tablets) daily, using cleaning and disinfecting products labeled to kill flu and coronaviruses.
  • Diluted bleach solution can be made at home using 1 tablespoon of bleach for every 1 quart (4 cups) of water, or a quarter cup of bleach to 1 gallon (16 cups) of water.

Close household contacts or those who have had unprotected exposure to saliva, respiratory, or other body secretions of the infected person should monitor for symptoms for 14 days after the exposure. If symptoms develop, they should follow the above steps.

Long-Term Monitoring

A confirmed case of MERS is "considered to no longer be infectious after two respiratory specimens (preferably lower respiratory tract) collected 24 hours apart are confirmed negative by the CDC rRT-PCR MERS-CoV assay, and the patient has clinical improvement," according to the CDC.

The CDC updated Interim US Guidance for Monitoring and Movement of Persons with Potential Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Exposure in June 2016 with detailed public health recommendations for managing and monitoring potential exposures during travel and other situations.

 

Medication

Medication Summary

No medications have been approved for the treatment of coronavirus infections. Clinical trials are needed to establish any benefit from ribavirin and/or interferon alfa.