Middle East Respiratory Syndrome (MERS) is a viral respiratory illness that was discovered in humans in 2012 in Saudi Arabia. The virus which causes MERS is called MERS-CoV (Middle East Respiratory Syndrome – Coronavirus) and is from a family of viruses, the Coronaviruses, which has a total of 25 known species ¹ . The majority of Coronaviruses are common viruses that produce mild to moderate upper respiratory tract infections that most humans will contract at some point in their lifetime ¹.

A notable member of the Coronavirus virus family is SARS-CoV (Severe Acute Respiratory Syndrome). SARS was officially discovered in early 2003 and was an extremely contagious coronavirus variant that affected patients around the world ¹³.

MERS has proven to be less contagious than its sibling SARS, however by no means should it be ignored. As of July 2014, 837 laboratory-confirmed cases were reported to the World Health organization with at least 291 of those cases resulting in a reported patient death ². Currently, the worldwide mortality rate is estimated at 27% and the specifics of the disease of are still being discovered².

MERS typically presents itself with a variety of non-specific symptoms, these include:

• Fever ^{1, 8}
• Cough
• Shortness of Breath
• Pneumonia
• Diarrhea
• Headache
• Dyspnea ²
• Myalgia ²

The majority of the current published clinical information is based off of data from critically ill patients. The wide variety of flu or pneumonia like symptoms make MERS especially difficult to diagnose upon admission without a laboratory verification ⁸. It is believed that the median time from illness onset to hospitalization is approximately 4 days 3 . The incubation period for human to human transmission is believed to be between 2 and 14 days ³.

The natural reservoir, or source of the MERS-CoV virus is not yet fully understood ^{3, 11}. It is believed to be zoonotic (originally from an animal) and to have originated possibly in bats, or camels native to the Arabian Peninsula ^{3, 10, 11}. It is then believed to be transmitted to humans from an infected animal. Currently, the CDC and WHO recommend advising people traveling to the Arabian Peninsula to:

• Avoid contact with visibly sick animals ³.
• Practice general hand washing and hygiene measures when in farms, barns, or markets ³.
• Avoid uncooked or unpasteurized camel meat and milk ^{10, 11}.
• Avoid the consumption of camel urine ^{10, 11}.
• Avoid close contact with visibly sick people.
• If possible, use a facial mask when among large crowds or among animals ¹².
• If working among camels, wear a face mask when possible and avoid contact with camel secretions¹². Wash any soiled clothing or shoes separately.

It is not yet fully understood how the virus is transmitted to humans and how the virus can pass onto other people. MERS appears to be somewhat contagious in situations where there is close contact with an infected patient (such as providing unprotected care to a patient or among family members) ⁸. Throughout the Arabian Peninsula there have been clusters of cases in health-care facilities where human-to-human transmission of the virus appears to be more efficient ¹.

In regards to a potential MERS case, a patient should be further evaluated if they have the following characteristics:

• Pneumonia and Fever or acute respiratory distress syndrome (With clinical or radiologic evidence) and:
  • Traveled to countries in or near the Arabian Peninsula within 14 days of symptom onset ¹¹. OR -
  • Came into close contact with a symptomatic traveler who developed fever and acute respiratory illness within 14 days of traveling to countries near or in the Arabian Peninsula ⁷ . OR -
  • A member of a cluster of patients with severe acute respiratory illness of unknown etiology in which MERS-CoV is being evaluated in consultation with state and local health departments ².
• OR –
• The patient has fever and symptoms of respiratory illness (does not necessarily have to be pneumonia) and was in (as a patient, worker, or visitor) a health care facility in which recent healthcare-associated cases of MERS had been identified within 14 days of symptom onset ⁶.
• Note: Patients with serious pre-existing conditions (cancer, diabetes, heart disease, etc.) are more likely to become infected with MERS ^{3, 6, 10}.
• Note: Countries included in the “in and near the Arabian Peninsula” description include – Bahrain, Iraq, Iran, Israel, the West Bank and Gaza, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syria, the United Arab Emirates (UAE), and Yemen ⁶.

Patients with the above listed risk factors should be evaluated for the MERS-CoV infection. In consultation with the local state and health departments, community or traveling contacts of the ill person should also be evaluated⁵. Health care providers should inform the CDC immediately once a patient has been deemed under investigation.

Currently, there are no vaccines available for the MERS-CoV and the treatment options are supportive in nature ¹¹. Standard treatment options include:

• Supportive care to alleviate general symptoms.
• In severe cases, supportive care to aid vital organs.

Heath care providers have been found to be at particular risk of becoming infected if proper barrier protections are not in place. The CDC recommends a variety of safety protocols when handling a confirmed or suspected MERS patient. Standard precautions include:

• Hand hygiene and PPE (Personal Protective Equipment) to avoid direct contact with patient’s blood, body fluids, and secretions ⁷.
• When providing care to patients that have respiratory symptoms (sneezing, coughing, etc.) use eye protection and a medical mask^2,6,10 .
• A medical mask should be worn by any personnel working within 1 meter of the patient ⁸.
• In the event that multiple patients have the same clinical diagnosis (and based on the epidemiological risk factors listed above) they can be placed in the same room with at least 1 meter of separation between them ⁶.
• Patient movement should be limited and the patient must wear a mask when outside of their rooms.
• Place a single patient in a single room with its own bathroom – whenever possible. If possible the room in which any MERS patient is placed should be an AIIR (Airborne Infection Isolation Room) or at the very minimum a room in which the air is recirculated using a high-efficiency particulate air (HEPA) filtration ⁶.
  • If this is not available, the patient, or patients, should be moved to a facility in which AIIR rooms are available. In the meantime, the patient should wear a mask at all times ⁶.
• Visitors to patients should be monitored and recorded ⁶.

The airborne precautions are based off of the lessons that were learned during the SARS epidemic. Aerosol-generating procedures (such as a tracheotomy and manual ventilation before intubation) should be performed by health care providers that are wearing the required PPE. The required PPE includes:

• Gloves and long sleeved gowns
• Eye protection
• Particulate respirators (N95 or equivalent). If these are not available a mask and face shield must be worn ⁷.
• If possible, an adequately ventilated single room should be used during an aerosol-generating procedure ^{7, 12}.

Listed below are other evidence based strategies for handling patients with MERS:

• Give supplemental oxygen therapy to patients with severe respiratory distress. Do not restrict oxygen because of concerns about a patient’s respiratory drive.
• Routine clinical specimens should be collected from the upper respiratory tract and lower respiratory tract.
  • Testing should be done by reverse-transcriptase polymerase chain reaction ^{7, 12}.
  • The CDC and State health authorities have lists of all laboratories that will be able to handle MERS-CoV within your area.
• Local and state health authorities must be informed of any suspected MERS cases ³. Ensure that any lab work is tested in a laboratory that is approved for MERS-CoV testing using the CDC’s MERS-CoV rRT-PCR assay.
• In the event that a patient with MERS needs to be transported to another facility, this should be done solely by Air Medical Transport⁷.
  • The minimum amount of necessary people should be on the trip and all members of the team must wear proper PPE. The patient should be situated as far from the cabin as possible (at least 6 feet away if possible) ⁷.

The countries in which the MERS-CoV virus has been identified have populations in which Islam is the predominate faith. Accordingly, patients or travelers from this region may have a variety of cultural sensibilities that are necessary to consider in order to provide respectful health care. Several key cultural considerations include:

• The patient may request to be treated or examined by a member of the same sex. Men may request to be examined or treated by a male nurse ^{4, 5}.
  • If this is not possible – a female patient may request that their husband or family member is present during an examination or treatment ^{4, 5.}
• ^{​​​​​}Respect of privacy should be practiced. Hospital personnel should knock before entering a room.
• Female patients may request a family member of the same sex to aid in washing or using the restroom ⁴.
• Traditionally the left hand is viewed as unclean ⁴. Medicine administration or feeding should be performed using the right hand whenever possible.
• Some Muslim women will insist on covering their whole bodies (except face, hands, and feet) at all times ⁵. Hospital gowns should be long and with long sleeves (“modesty gowns”). These gowns normally extend to the ankle and have snaps instead of ties in the back ⁵. If such clothing is unavailable the patient should be allowed to use their own gowns.
• It is an Islamic cultural and religious practice to visit the sick ⁵. Openness and clear communication of any restrictions should be conveyed.
  • Friday is the religious holy day and as such there may be a large amount of visitors and family on Fridays ⁴.
• Unnecessary touching should be kept to a minimum. Eye contact, especially with women, should be kept to a minimum ⁴.
• The patient may have dietary preferences: Muslim Halal (similar concept to Kosher) meals should be provided ⁵. If these are not available then Jewish Kosher meals or vegetarian meals are acceptable.
  • Pork, ham, lard, bacon, and alcohol are strictly prohibited ⁵. If there are no further clinically indicated dietary restrictions, allow the patient to bring food from home.
  • The patient may inquire if a specific medication contains alcohol or pork based glycerin⁵. Open and honest communication is necessary.
• Daily prayer is an important part of many active Muslims’ faith. Adequate facilities or processes should be available to patients. Establish a process for patients with contagious disease that takes into account daily prayer needs ⁴.
• In the event that a patient has died, the family may ask for the face and right shoulder of the deceased to be turned in the direction of Mecca ⁴. Preferably, the body should be covered and handled as little as possible and Muslim burials are typically performed as soon as possible ⁴. Openness and communication are key to explaining the precautions necessary when handling a potentially contagious patient’s dead body. Check with your state’s local health administration for additional advice on handling and turning over a potentially contagious body to people of the Islamic faith.
  • Autopsies are generally discouraged unless required by law. In the event that one is needed – open communication is necessary.

Although MERS-CoV is a relatively new virus, it has made its mark on the global conscious. Due to the ease of travel to the Middle East and the generic initial symptoms, it is crucial that health care providers are aware of the precautions and necessary steps for the safe management of a patient with MERS.

1) Coronavirus Infections. (2014). The World Health Organization. Retrieved from: http://www.who.int/csr/disease/coronavirus_infections/en/
2) Clinical Management of Severe Acute Respiratory Infections When Novel Coronavirus is suspected: What to do and what not to do. (2013). The World Health Organization. PDF retrieved from: http://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf
3) Frequently Asked Questions on Middle East Respiratory Syndrome Coronavirus (MERS-CoV). (2014). The World Health Organization. Retrieved from: http://www.who.int/csr/disease/coronavirus_infections/faq/en/
4) Gulam, Hyder. (2003). Care of the Muslim Patient. ADF Health. Vol. 4. 80-83. Retrieved from: http://www.defence.gov.au/health/infocentre/journals/ADFHJ_sep03/ADFHealth_4_2_81-83.pdf
5) Guidelines for Health Care Providers Interacting With Muslim Patients and Their Families. (2006). International Strategy and Policy Institute. Retrieved from: http://www.ispi-usa.org/guidelines.htm
6) Interim Guidance for Health Professionals. (2014). The Centers for Disease Control and Prevention. Retrieved from: http://www.cdc.gov/coronavirus/mers/interim-guidance.html
7) Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV). (2014). The Centers for Disease Control and Prevention. Retrieved from:
http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html
8) MERS Clinical Features. (2014). The Centers for Disease Control and Prevention. Retrieved from: http://www.cdc.gov/coronavirus/mers/clinical-features.html
9) MERS Corona Map. (2014). Corona Map. Retrieved from: http://coronamap.com/
10) Middle East Respiratory Syndrome. (2014). The Centers for Disease Control and Prevention. Retrieved from: http://www.cdc.gov/CORONAVIRUS/MERS/
11) MERS in the Arabian Peninsula. (2014). The Centers for Disease Control and Prevention. Retrieved from: http://wwwnc.cdc.gov/travel/notices/alert/coronavirus-saudi-arabia-qatar
12) Salazar, David and Bronze, Michael. (2014). Middle East Respiratory Syndrome (MERS). Medscape Online Periodical. Retrieved from: http://emedicine.medscape.com/article/2218969-overview
13) Severe Acute Respiratory Syndrome (SARS). (2014). Wikipedia. Retrieved from: http://en.wikipedia.org/wiki/Severe_acute_respiratory_syndrome