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, and with 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 US 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 US 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] :
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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.
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Restrict visitors and nonessential household members, especially those who are older or immunocompromised.
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Wear a disposable surgical face mask when around other people or in public and replace it every few hours.
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Avoid touching the face whenever possible. Wash hands frequently with soap and water or use an alcohol-base hand sanitizer often.
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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.
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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.
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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.
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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.
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Vero cells infected with Middle East respiratory syndrome coronavirus (MERS-CoV). Image courtesy of the Centers for Disease Control and Prevention (Jennifer L. Harcourt).
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MERS-CoV virion on electron microscopy, illustrating ultrastructural detail. Image courtesy of the Centers for Disease Control and produced by the National Institute of Allergy and Infectious Diseases (NIAID), 2014.
