MIDDLE-EAST RESPIRATORY SYDROME

Wiwik Udayani
Negara yang terserang

• Ada 9 negara yang telah melaporkan kasus MERS-CoV (Perancis,

Italia, Jordania, Qatar, Arab Saudi, Tunisia, Jerman, Inggris dan Uni
Emirat Arab).
• Semua kasus berhubungan dengan negara di Timur Tengah (Jazirah
Arab), baik secara langsung maupun tidak langsung
Kondisi Indonesia saat ini

• Sejak September 2012 s/d 01 Agustus 2013 jumlah kasus MERS-CoV

yang terkonfirmasi secara global sebanyak 94 kasus dan meninggal 47
orang (CFR 50 %).
• Hingga saat ini belum ada laporan kasus di Indonesia
Situasi Perkembangan Terkini Kasus MERS-
CoV (WHO 2013)
Pengertian MERS-CoV

• MERS-CoV adalah singkatan dari Middle East Respiratory Syndrome

Corona Virus.
• »»Virus ini merupakan jenis baru dari kelompok Coronavirus (Novel
Corona Virus).
• »»Virus ini pertama kali dilaporkan pada bulan Maret 2012 di Arab
Saudi.
• »»Virus SARS tahun 2003 juga merupakan kelompok virus Corona
dan dapat menimbulkan pneumonia berat akan tetapi berbeda dari
virus MERS-CoV .
Pengertian MERS-CoV

• MERS-CoV adalah penyakit sindrom pernapasan yang disebabkan

oleh virus Corona yang menyerang saluran pernapasan mulai dari yg
ringan sampai berat.
• Gejalanya adalah demam, batuk dan sesak nafas, bersifat akut,
biasanya pasien memiliki penyakit ko-morbid.
• Median usia 49,5 tahun (range 2-94 tahun).
• 64 % kasus laki – laki.
• Manifestasi klinik MERS-CoV rentang variasi
sangat lebar
• Pasien disertai ko-morbid mortaliti
meningkat
• Kesenjangan pengetahuan, epidemiologi,
prevalensi dan spektrum klinik memerlukan
panduan definisi yang urgen
 DEFINISI KASUS
•CURIGA (SUSPECT)
•MUNGKIN (PROBABLE)
•PASTI (CONFIRMED)
CURIGA (Suspect) MERS Co-V
KRITERIA KLINIK:
Seseorang yang menunjukkan :
• Infeksi respirasi akut, panas (≥ 38°C) dan batuk; DAN
• Dicurigai kelainan parenkim paru (mis. Pneumonia atau ARDS
berdasar klinis atau radiologis adanya konsolidasi); DAN
• Riwayat kembali dari jazirah Arab atau negara sekitarnya dalam
waktu 14 hari; DAN
• Gejala yang tidak dapat dibuktikan karena penyakit infeksi lain atau
sebab yang lain termasuk pemeriksaan untuk CAP
CURIGA MERS Co-V

Penderita yang memerlukan evaluasi MERS-

Co-V
• Penyakit saluran pernapasan bawah berat dengan
sebab diketahui, 14 hari yang lalu bepergian ke
Arab atau sekitar , tidak respons terhadap terapi
yang tepat; ATAU
• Pasien dengan gejala sama, ada riwayat kontak
langsung dengan orang dengan gejala panas dan
penyakit pernapasan akut yang baru pulang dari
Arab
MUNGKIN (Probable) MERS Co-V

• Klinik, Radiologis dan histopatologis memenuhi

definisi curiga MERS Co-VA (i.e Pneumonia or
ARDS) tapi tidak ada bukti kepastian
laboratorium, DAN
• Kontak langsung dengan kasus yang sudah pasti,
DAN
• Tidak bisa dijelaskan penyebab atau infeksi lain
termasuk tes untuk CAP, ATAU
• Setiap orang dengan Penyakit pernapasan akut
berat yang tidak diketahui penyebabnya DAN
epidemiologis berhubungan dengan kasus pasti
PASTI MERS Co-V

•Secara laboratoris menunjukkan

MERS Co-V
GEJALA KLINIS
Panas

• Suhu >38oC
• Bila tidak ada panas , gunakan keputusan klinis
• Faktor yang harus dipertimbangkan :
Pasien melaporkan pernah panas
Meminum antipiretik
Kondisi Immunocompromised
Konsumsi immunosuppressants
Manula, Tak ada alat ukur suhu
Assiri 2013
GAMBARAN RADIOLOGIS

Lesi perifer, umumnya

menyebar dari kesuraman
fokal unilateral ke unilateral
multifokal atau bilateral ,
selama pengobatan
Imaging findings at presentation in Saudi patients with Middle East respiratory syndrome
(A) Chest radiograph of a 61-year-old man, showing bilateral fine reticulonodular air-space
opacities, increased vascular markings, and cardiomegaly. Assiri 2013
Imaging fi ndings at presentation in Saudi patients with Middle East respiratory syndrome (B)
Chest radiograph of an 83-year-old man, showing right lung consolidation, right basal pleural thickening,
and reticulonodular air-space opacities; rib fractures on the right are old. Assiri 2013
Imaging fi ndings at presentation in Saudi patients with Middle East respiratory syndrome (C)
Chest radiograph of a 56-year-old man, showing extensive bilateral extensive diff use and focal alveolar
space opacities, with opacifi cation of the left lower lobe. Assiri 2013
Imaging fi ndings at presentation in Saudi patients with Middle East respiratory syndrome(D)
Chest radiograph of a 67-year-old man, showing extensive bilateral disease, with diff use alveolar space
densities, opacifi cation, reticulonodular opacities, and bronchial wall thickening. Assiri 2013
Imaging fi ndings at presentation in Saudi patients with Middle East respiratory syndrome(E)
Chest radiograph of a 49-year-old man, showing extensive bilateral mid and lower zone disease, with
diff use reticulonodular alveolar space opacities. A thoracic CT scan in the same patient. Assiri 2013
Pneumonia Berat

• Dewasa
• Panas atau
• Suspek infeksi
• Batuk
• RR > 30 /min
• Distres napas berat
• Saturasi oksigen (SpO2) < 90% udara kamar
Sindroma Distres Pernapasan Akut (ARDS)

•Onset :Akut (dalam 1 minggu

simtom respirasi memburuk)
•Foto atau CT Scan : kesuraman
bilateral, bukan efusi, lobar/paru
kolaps atau nodul
•Edema paru : tidak karena jantung
atau kelebihan cairan
Sindroma Distres Pernapasan Akut (ARDS)

•Derajat hipoksemia :
ARDS ringan : 200 mm Hg < PaO2/FiO2 ≤ 300
mm Hg dengan PEEP or CPAP ≥ 5 cm H2O
ARDS sedang 100 mm Hg < PaO2/FiO2 ≤ 200
mm Hg dengan PEEP ≥ 5 cm H2O
ARDS berat PaO2/FiO2 ≤ 100 mm Hg dengan
PEEP ≥ 5 cm H2O
Bila PaO2 tidak ada, rasio O2/FiO2 ≤ 315
menyokong ARDS.
Penyakit Infeksi Respiratori

•Influenza A and B
•Respiratory syncytial virus
•Streptococcus pneumonia
•Legionella pneumophila
NEGARA ARAB KELOMPOK MERS Co-V

Yang termasuk negara yang dicurigai:

•Bahrain
•IraK
•Iran
•Israel
•Jordan
•Kuwait
•Libanon Oman, teritori Palestina, Qatar, Arab Saudi, Syria, the Uni
Emirat Arab (UAE), and Yaman
Cara penularan MERS-CoV

• Virus ini dapat menular antar manusia secara terbatas, dan tidak
terdapat transmisi penularan antar manusia secara luas dan
bekelanjutan. Mekanisme penularan belum diketahui.
• Kemungkinan penularannya dapat melalui :
Langsung : melalui percikan dahak (droplet) pada saat pasien batuk
atau bersin.
Tidak Langsung: melalui kontak dengan benda yang terkontaminasi
virus.
Kontak Langsung (Close Contact)

•Sebagai petugas kesehatan turis

yang sakit (eg, pekerja puskesmas
atau anggota keluarga ), atau
mempunyai
•Berada satu tempat atau atau
kontak fisik dengan turis yang sakit
KO-MORBIDITI
Assiri 2013
Pencegahan

Pencegahan dengan Prilaku Hidup Bersih dan Sehat (PHBS)

• Menghindari kontak erat dengan penderita
• Menggunakan masker
• Menjaga kebersihan tangan dengan sering mencuci tangan dengan
memakai sabun dan menerapkan etika batuk ketika sakit
LABORATORY CONFIRMATION c/o RITM Virology
DETEKSI MIDDLE EAST RESPIRATORY
SYNDROME CORONAVIRUS (MERS-
COV) DENGAN PCR PADA JAMA’AH
HAJI SEBAGAI UPAYA PENANGKAL
INVASI MERS-COV KE WILAYAH
JAWA TIMUR

21 OKTOBER-28 NOVEMBER 2014

Skrining MERS Co-V Jamaah Haji Debarkasi Surabaya 2013
 Critical features of MERS-CoV (1) : the Epi of MERS-CoV

• Pattern of the epidemic

• Repeated sporadic introductions into the human population
from direct or indirect contact with dromedary camels
• Resulting in limited human-to-human transmission,
notably in healthcare settings
• No evidence of sustained human-to-human transmission**

• Source of infection
• Approximately half of all cases reported to date are
health care associated
• Not all community acquired infections report direct
or indirect contact with dromedaries* Health care associated MERS outbreaks
• No cases associated with religious pilgrimages

• Reasons for outbreaks

• Failures in infection control and prevention in healthcare settings
have resulted in large numbers of secondary cases
• Cultural practices, crowded facilities, extended stays in
emergency departments
Critical features (2): Risk of Infection- dromedary to human

• Ample evidence that dromedary camels play an

important role in transmission in the
region

• Virus has been detected in dromedary camels in:

• Qatar, Saudi Arabia, UAE, Oman and Egypt
• Antibodies have been found in camels in:
• Jordan, Tunisia, Ethiopia, Nigeria, Egypt, Oman, Kenya,
Saudi Arabia, Canary Islands, UAE…
• Human and camel viruses closely related

• Occupationally exposed = higher risk of infection (several

presentations will address this)

• Risk factors for infection are unclear

• Several studies are being planned/ are ongoing
• Few have clearly addressed this fundamental question
• Recent case-control study from Qatar* (presentation later)

*Sikkema et al JID 2017

 Q: Apa itu virus corona?
Virus corona merupakan virus yang
umum yang sebagian besar orang
pernah terinfeksi selama hidup

Virus corona manusia biasanya

menimbulkan ISPA ringan –sedang
pada 25% Common cold.
 Q: Apa itu virus corona?

Mengapa disebut Virus corona?

Karena glycoprotein seperti paku
dipermukaan tampak dengan EM
dan mengelilingi seluruh virus
seperti mahkota
EM Picture. Diagrammatic
 Single-stranded RNA virus 30 000
nucleotide, positive-sense, enveloped.
 Enveloped virus i.e. not affecting GIT die out
due to gastric secretions.
 3 groups of the virus affecting human and
animals.
 Coronavirus can undergo dramatic change in
virulence and tissue tropism e.g. change in
spike gives SARS-CoV or MERS-CoV.
Group Representative Virus
Group 1 Human coronavirus 229E (HCoV-229E) Human coronavirus NL63
(HCoV-NL63) Canine enteric coronavirus (CCoV) Feline
coronavirus (FCoV)
Porcine transmissible gastroenteritis coronavirus (TGEV) Porcine
epidemic diarrhoea coronavirus (PEDV)
Bat coronaviruses (BtCoVs)

Group 2 Human coronavirus HKU1 (HCoV-HKU1) Bovine coronavirus

(BCoV)
Canine respiratory coronavirus (CRCoV)
Porcine hemagglutinating encephalomyelitis coronavirus (HEV)
Murine hepatitis coronavirus (MHV) Feline infectious peritonitis
virus (FIPV) SARS coronaviruses (SARS-CoVs) Bat
coronaviruses (BtCoVs)

Group 3 Infectious bronchitis coronavirus (IBV)

Turkey coronavirus (TCoV)
Pheasant coronavirus (PhCoV)
 No; it affects human
allover the world and was
known since 1960s.
Affecting all people but
mostly children.
Causing 25% of Colds.
The only severe form of
it was SARS-CoV who
disappeared since 2004.
Direct and Indirect contact.

Droplet infections.

But still needs to be more

determined.
 It is mild to moderate upper respiratory
tract infection “cold”.

 Re-infection of the individual with the

same serotype can occur within months
i.e. short lived immunity.
The first new one was called SARS-CoV.

The running one nowadays is the Middle

East Respiratory Syndrome corona virus
“MERS-CoV”.
Appeared in 2002 in China.
Emerged from animal reservoir.
 IP 2-14 days, droplet infection.
Affected 8000 patients in 29 countries
of the world .
Had 9.6% Mortality rate (744 cases).
Disappeared in 2004.
Low pathogenicity, not transmitted
from human to human, no vaccine.
 Appeared in 2012.
Human –to-human transmission
confirmed.
Mode of transmission not yet confirmed.
(respiratory secretion, direct & Indirect
contact)
Reservoir of infection not yet determined.
(from Bats to Camels to Humans?)
Incubation period (2-14 days) not yet
confirmed.
 Based on DNA sequencing, researcher speculate that MERS coronavirus started
in infected bats in Egypt or the horn of Africa (left panel). They suspect that the
winged mammals transmitted the microbe to one-humped camels, where the virus
circulated possibly for decades, before hopping into humans. Since camels are
an accessible intermediate host, some groups have proposed vaccines for the
hooved animals to prevent future spread to humans. Source: Papaneri, AB et al.
Expert Rev. Vaccines. 2015.
Are we the
reservoir of
MERS CoV
my dear??
Calm down
my dear
we love
you
anyway
1* Suspected cases:
• A- ADULTS (> 14 years):
I.Acute respiratory illness with clinical and/or
radiological, evidence of pulmonary
• parenchymal disease (pneumonia or Acute
Respiratory Distress Syndrome (ARDS).

II.A hospitalized patient with healthcare

associated pneumonia based on clinical and
radiological evidence.
III. Upper or lower respiratory illness within 2
weeks after exposure to a confirmed or
probable case of MERS-CoV infection

IV- Unexplained acute febrile (≥38°C) illness,

AND body aches, headache, diarrhea, or
nausea/vomiting, with or without respiratory
symptoms, AND leucopenia (WBC < 3.5 x
109/L) and thrombocytopenia (platelets
<150 x 109/L).
I.Meets the above case definitions and
has at least one of the following
a. History of exposure to a confirmed or
suspected MERS CoV in the 14
days prior to onset of symptoms
b. History of contact with camels or
camel products in the 14 days prior
to onset of symptoms
II. Unexplained severe pneumonia.
A probable case is a patient in category I or
II above (Adult or pediatrics) with
inconclusive laboratory results for MERS-
CoV and other possible pathogens who is a
close contact of a laboratory-confirmed
MERS-CoV case OR who
works cases
hospital where MERS-CoV in are cared
a
for OR had recent contact with camels or
camel’s products.
A confirmed case is a suspect case with
laboratory confirmation of MERS-CoV
infection.

 More information about case definitions: 1- WHO:

http://www.who.int/csr/disease/coronavirus_infections
/case_definition_jul2014/en/ 2- CDC:
http://www.cdc.gov/coronavirus/mers/case-def.html
1 E xclude other causes of pneumonia and respiratory tract
infections.
2 The suitable samples are sputum, BAL, tracheal aspirate

(No VTM).

3. Swabbing of nasopharynx, nose/throat, on VTM.

4. All samples are to sent to the lab immediately or kept frozen in dry ice > 24 H.

5. Serum for serology or virus detection and EDTA whole blood for PCR.
N.B.
The diagnostic test approved and
applied by the MOH is the PCR one.

Serology by finding seroconversion in

double samples is applied by some other
countries.
 Units Recommended distances
General ward A minimum of 1.2 meters between beds

Critical care unit (ICUs) A minimum of 2.4 meters between beds

Hemodialysis Units A minimum of 1.2 meters between beds

Emergency Units A minimum of 1.2 meters between beds

3– Environmental ventilation in all areas within a

health-care facility.
4– Environmental cleaning and/or disinfection.
5– Prevention of needle-stick or sharps injury.
6– Safe waste management (Medical waste).
1-
Isolation:
 Air Pumping & suction separated from hospital

HEPA filter Anteroom

Pressure Monitor

Private Bathroom
- Non-critically ill: segregated single room
+HEPA, AGP in negative pressure room.
- Critically-ill: airborne negative
pressure
isolation room.
-If not available : well ventilated single room
-If not available: cohorting
-If not available: put patients in beds with
1.2 meters distances.
- Transport of patient limited and
prepared if necessary and patient must
wear surgical mask on transport.
A must when caring isolated patients.
 Donning order:
1- HH2- Gown
3- Mask (surgical for rooms & N95 for airborne)
4- Eye protection 5- Gloves
 Doffing order in anteroom:
 1- Gloves, 2- Eye protection,
 3- Gown 4- Mask (removed outside
negative pressure
room). 5- HH
 Fittest is a must for HCWs entering negative
pressure and performed annually.
 For mild cases of MER-CoV infections.
 Home should be suitable for isolation.
 Instructions for the patient in home isolations to
be clear and followed.
 Instructions for the care givers to the patient at
home.
 Instructions for the other house-hold contacts.
 Close contacts to be followed for 14 days for
any symptoms or signs of MERS.
 High-risk unprotected exposure (Contact with
confirmed MERS-CoV case within 1.5 meters for >
10 minutes): single swabbing, off work till
negative results.
 Low-risk unprotected exposure (Contact with
confirmed MERS-CoV case more than 1.5 meters
and/or for < 10 minutes): continue work and not
testing.
 Protected exposure (Contact with confirmed
MERS-CoV case and having appropriate isolation
precautions including the PPE): continue work and
no testing.
 Definitely unknown
 However it is guided by clinical picture and 2
negative lower respiratory samples for MERS-
CoV.
 Negative samples to be repeated after 1 week for
improving patient.
 No need for repeated sampling for non-improving
patient.
 Home-isolated patients to be tested after 1
week isolation and then every 3 days, stop
isolation
when patient is asymptomatic or negative single
Terima kasih