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This guidance supersedes guidance previously found in ‘MERS-CoV: public health investigation and management of possible cases’ and ‘MERS-CoV: public health investigation and management of close contacts of confirmed cases’.

When to suspect Middle East respiratory syndrome

Who is this guidance for

This guidance is for healthcare professionals and health protection teams (HPTs) on ³Ù³ó±ð identification and management of cases of Middle East respiratory syndrome (MERS), which is caused by Middle East respiratory coronavirus (MERS-CoV).

More information about MERS-CoV can be found online.

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°ä´Ç²Ô²õ¾±»å±ð°ùÌýMERS-CoV if a patient meets one of ³Ù³ó±ð 2 possible case definitions below:

GroupÌý1: High symptom severity,ÌýwiderÌýepidemiological link

Any person withÌýsevereÌýacute respiratory infectionÌýwhoÌýrequires admission to hospitalÌýandÌýhas evidence of pulmonary parenchymal disease (for example, clinical or radiological evidence of pneumonia or acute respiratory distress syndrome (ARDS))Ìý(²õ±ð±ð note 1)

andÌýat least one of the following in theÌý14 daysÌýbefore the onset of symptoms:Ìý

• contact with a confirmed case of MERS-CoV infection (see contact tracing matrix, belowÌýfor examples of contact)Ìý

• a history of travel to, or residence in,Ìýa country in list AÌý(box 1)

• an unusual or unexpected clinical course, especially sudden deterioration despiteÌýappropriate treatment, with unknown place of residence or history of travel

GroupÌý2: Low symptom severity,ÌýnarrowerÌýepidemiological link

Any person presenting withÌýanÌýacute respiratoryÌýinfectionÌýof any degree of severity (symptomsÌýmayÌýincludeÌýfever,ÌýcoughÌýor shortness ofÌýbreath) (see note 1) andÌýoneÌýof the following in the 14 days prior to onset:Ìý

• contact with a confirmed case of MERS-CoV (see contact tracing matrix for examples of contact)Ìý

• contact with camels or camel environments, or consumption of or contact with camel products (for example, raw camel milk or camel urine) in country list A (box 1)Ìý

• attendanceÌýatÌýa hospitalÌýin country list AÌýor contact with people who have attended a hospitalÌýin country list AÌý(box 1)Ìý

• occupational exposure to camels (for example, in animal husbandry or abattoirs) or consumption of or exposure to camel products (for example, raw camel milk or camel urine) in country list BÌý(box 1)

Note 1: gastrointestinal symptoms may also be present and there is a possibility of atypical presentation, such as absence of fever, particularly in patients who are immunocompromised as per theÌýGreen Book.

Any individual who has not had a relevant exposure, as detailed in the 2 groups within the last 14 days before onset of illness is not considered to be at risk of MERS-CoV.

Actions for a case of MERS-CoVÌý

For all suspectedÌýMERS-CoVÌýcases

Clinical assessment and risk stratification should be conducted for all individuals meeting the case definitions above, as well as for symptomatic contacts of probable and confirmed cases as described in the section for health protection teams (HPTs) below.

All patients under assessment for suspected MERS should immediately be isolated in a single side room, ideally at negative pressure. Additional IPC measures and personal protectional equipment (PPE) should be implemented as per local trust policy, including appropriate handling of waste, linen and specimens. Further guidance can be found in the and the .

Individuals not requiring hospital admission should be provided with advice on self-isolation pending their test result.

MERS is a high consequence infectious disease (HCID) and suspected cases should be discussed with local infection services before testing.

MERS is a notifiable disease and the local health protection team (HPT) should be urgently notified of any possible cases being tested. The local HPT can contact the Acute Respiratory Infections team (ARI) at acute.respiratory@ukhsa.gov.uk in hours for advice, or the Epidemic and Emerging Infections (EEI) on-call consultant out of hours, via the UKHSA switchboard on 020 7654 8000.

Testing for MERS-CoV

Instructions for ³Ù³ó±ð minimum diagnostic sample set and referral of samples to laboratories for testing is available in MERS-CoV: diagnostic testing guidance guidance and in ³Ù³ó±ð laboratory testing flowchart forÌýMERS-CoV. 

Case definitionsÌýfor use by HPTs

Who is this guidance forÌý

This guidanceÌýisÌýfor health protection professionals to guide public health actions for cases of MERS and their contacts, as per theÌýcontact tracing matrix below.

Possible case: anyÌýindividual whoÌýfalls intoÌýone of theÌý2Ìýgroups of suspect MERS cases and and for whom polymerase chain reaction (PCR) testing is pending.Ìý

Probable caseÌý(box 2): anyÌýindividualÌýin whomÌýMERS-CoVÌýhas been detectedÌýbyÌýPCRÌýatÌýan NHS laboratory with validated MERS-CoV testingÌýorÌýaÌýUKHSAÌýand Collaborating NHSÌýClinical Network Laboratory (CNL)ÌýandÌýis pending confirmatory testing in theÌýreference laboratoryÌýUKHSA Respiratory Virus Unit.Ìý

Confirmed case: any individualÌýinÌýwhomÌýMERS-CoVÌýhas beenÌýconfirmedÌýby PCRÌýby theÌýreference laboratoryÌýUKHSA RespiratoryÌýVirus Unit (RVU).Ìý

Discarded case: any individual who falls into one of the 2 groups of suspect MERS cases who has tested negative for MERS-CoV at an NHS laboratory with validated MERS-CoV testing or a CNL and in whom there is no ongoing clinical suspicion of MERS-CoV.

Instructions for theÌýminimumÌýdiagnostic sample set and referral of samples to laboratories for testing is available in MERS-CoV: diagnostic testingÌýand in the diagnostic testing flowchart for MERS-CoV.

ActionsÌýforÌýpossibleÌýMERSÌýcases

ThisÌýsectionÌýis for clinical and public health professionals to guide the investigation and management ofÌýpossibleÌýMERSÌýcases. Further information on clinical presentation can be foundÌýin the Clinical assessment section. For case status definitions, seeÌýCase definition status for use by HPTs below.

Testing pathwayÌý

Follow theÌýguidance in MERS-CoV: diagnostic testing.Ìý

Samples shouldÌýnotÌýbeÌýsentÌýto the UKHSA reference laboratory Respiratory Virus Unit (RVU) for primary testing.Ìý

Reporting and public health actionsÌý

HPTs should complete the abridged MDS form (minimum dataset form) and inform the following that testing will be carried out:

• ³Ù³ó±ð UKHSA Acute Respiratory Infections team via acute.respiratory@ukhsa.gov.ukÌý(in hours), or the Epidemic and Emerging Infections (EEI) consultantÌýon-callÌý(out-of-hours) by phone

HPTs should advise isolation until test results available. Self-isolation at home pending test results may be appropriate if the patient is considered well enough for discharge following clinical assessment, taking in to account local risk-stratification including that they:

• can travel home by private vehicle, driven by the patient or a household member (the patient should sit in the back seat on the opposite side and wear a fluid resistant surgical mask, the windows should be kept open and there should be no other passengers); they should not travel by taxi or by public transport
• can understand and comply with the self-isolation advice below
• do not share a household with any individuals who are above the age of 65 years, immunosuppressed or have underlying conditions including diabetes, hypertension, chronic cardiac and renal disease

Self-isolation adviceÌý

Patients self-isolating atÌýhome pendingÌýtheir test result should be given the following advice:Ìý

• avoidÌýcontact with other household members
• doÌýnot shareÌýpersonal items suchÌýas towels, bed linen, toothbrushes or eating and drinking utensils such as cutlery or cups
• riskÌýassess if non-essential medical or dental treatment should be postponed (considering the risk of exposure, the risk of delaying the treatment and the potential risk to healthcare providers)
• forÌýessential treatment, the healthcare provider must be informedÌýbeforeÌýthe procedure or attendance at the healthcare facilityÌý
• adviseÌýnot to travel

For further guidance on self-isolating at home, seeÌýMERS-CoV: self-isolating awaiting MERS-CoV test result.

Actions forÌýprobableÌýandÌýconfirmed MERS casesÌý

Samples which test positive in aÌýlocalÌýNHSÌýlaboratory or UKHSAÌýand collaborating NHSÌýCNL should beÌýforwardedÌýurgently (same day)Ìýto RVU for confirmationÌýas per theÌýtesting flowchartÌýand testing guidance.Ìý

Cases are considered probable until confirmed as positive by RVU. Probable cases should be managed clinically in the same way as confirmed cases pending RVU confirmation.

All further samples from confirmed cases should be sent directly to UKHSA RVU and should include repeat respiratory tract sampling (upper and/or lower depending on clinical status), serological samples, and other samples depending on clinical status.

Reporting and public health actions for positive results

The consultant microbiologist or virologist or treating clinician should immediately report positive results from a local accredited laboratory or UKHSA CNL to ³Ù³ó±ð HPT (by phone).

The HPT s³ó´Ç³Ü±ô»å i²Ô´Ú´Ç°ù³¾â€¯t³ó±ð UKHSA Acute Respiratory Infections Team at:

• in hours: acute.respiratory@ukhsa.gov.uk
• out of hours: ³Ù³ó±ð EEI duty consultant via theÌýUKHSAÌýswitchboard on 020 7654 8000

For all positive MERS-CoV results, the following reporting and escalation actions should be undertakenÌýimmediately:

• the HPT should completeÌýthe MDS form and email this to the Acute Respiratory Infections Team at acute.respiratory@ukhsa.gov.uk during working hours, Monday to Friday, or the EEI duty consultant out of hours via the UKHSA switchboard on 020 7654 8000
• the acute respiratory infections team (in hours) or EEI consultant on-call (out of hours) should inform the National Response Centre (NRC) on-call (0300 303 3493) of any positive results for MERS-CoV. The NRC on-call should then notify the NHS England National EPRR Duty Officer, in line with alerting protocols
• theÌýNHS England NationalÌýEPRR Duty OfficerÌýwill liaise withÌýthe HCID clinical lead and coordinate activation ofÌýtheÌýHCID Network (airborne) to discuss appropriate placement and initial clinical management, as appropriate
• in parallel, theÌýrelevant NHS Trust shouldÌýfollow standard alert and escalation (on-call mechanisms) via their commissioner
• the expectation is that all positive MERS-CoV cases would be managed in a hospital setting via HCID pathways
• patients who are in the community at the time of a positive test result becoming available should be advised to self-isolate, pending transfer to an HCID centre, co-ordinated through EPRR mechanisms outlined above

ReportingÌýand public health actionsÌýforÌýconfirmed results

RVU should report all confirmed positive results by telephone toÌýthe:

• laboratory that produced ³Ù³ó±ð initial positive result 
• clinical laboratory that referred the sample initially 
• relevant CNL microbiologist or virologist
• local HPT 
• theÌýUKHSA Acute Respiratory Infections Team or EEI consultantÌýon-callÌý(out of hours)Ìý via the UKHSA switchboard on 020 7654 8000
• the UKHSA Acute Respiratory Infections team (in hours) or EEI consultant on-call (out of hours) should report all confirmed cases to the World Health Organization within 24 hours of confirmation via the national focal point at IHRNFP@ukhsa.gov.uk

De-isolationÌýand dischargeÌýof MERS ³¦²¹²õ±ð²õ 

This guidance has been produced by the UK Health Security Agency (UKHSA) to support NHS trusts in managing the de-isolation of patients with MERS-CoV infection. Arrangements for individual patients should be considered on a case-by-case basisÌýand must be made in conjunction with the managing clinical team and the HCID network.

De-isolation of a MERS-CoV confirmed case is based on the clinical presentation and the correct interpretation of the laboratory findings. De-isolation can be considered if the patient is judged to be clinically well enough for safe discharge by the clinical team managing the patient and the following conditions are met:

• the patient is at leastÌý10Ìýdays post onset of symptomsÌý(if symptomatic)Ìý
• their symptoms have resolvedÌý(if symptomatic)Ìý
• they have tested negative for MERS-CoV by PCR on 2 respiratory samples taken 24 hours apart from a site that was previously positiveÌý

If it is not possible to obtain a sample from a site that was previously positive (for example, because the patient has been extubated), orÌýthe patient remains symptomatic or PCR positive beyond 14 days, the need for repeat sampling and continued isolation should be discussed by theÌýincident management team, to include theÌýclinical team, the HCID network, the relevant HPT lead, the duty senior in the Acute Respiratory team at UKHSA and a virologistÌýfromÌýRVU.

Management of contactsÌýofÌýprobableÌýand confirmedÌýMERSÌýcases in UK settings

ThisÌýguidanceÌýshould be used for exposures toÌýprobable (sample positiveÌýat local NHS laboratory or CNL)Ìýor confirmedÌý(sample positive at RVU)Ìýcases ofÌýMERS.

It is aÌýpublic health responsibility:

• toÌýidentify, assess, and categorise contacts of aÌýsymptomaticÌýcase ofÌýMERS
• to appropriatelyÌýmonitorÌýcontacts 
• to arrange clinical assessment and testing for contacts who develop symptoms within 14 days of the last possible exposure 

Health protection teamsÌý(HPTs)Ìýshould conduct interviews withÌýprobable and confirmed confirmedÌýMERS cases, or their next of kin if they are too unwell, to identify contacts during their symptomatic period. Any individual who has not had contact withÌýaÌýcaseÌýin the last 14 days is not considered a contact.

Contact managementÌýand the requirement forÌýisolation or MERS-CoVÌýtestingÌýwill depend on the level of risk ofÌýcontact, which is described in theÌýcontact tracing matrix.Ìý

Active follow-upÌý(forÌýhigh exposure (category 3)Ìýcontacts)Ìý

For active follow-up, the health protection team (HPT) should have contact with the exposed person daily (by text, telephone, or email) for the 14 days following their last exposure to check if they have developed any symptoms compatible with MERS-CoV as described in the . HPTs should immediately refer any individual who develops symptoms for clinical assessment as a possible case as per NHS .

Passive follow-up (forÌýmedium (category 2) and low (category 1)Ìýcontacts)Ìý

For passive follow-up,ÌýtheÌýhealth protection team (HPT)ÌýshouldÌýprovideÌýthe exposed personÌýwithÌýinformation onÌýMERS-CoV,Ìýthe emergency contact instructions for the local HPT,ÌýandÌýinstructÌýthe individual to contact the HPT if they develop any of the clinical symptoms describedÌýin the case definitionsÌýin the 14 days following their lastÌýexposure.

HPTs shouldÌýimmediatelyÌýrefer any individual who develops symptoms compatible with MERS-CoV as described in theÌýcase definitionsÌýfor clinical assessmentÌýasÌýaÌýpossible case.

For NHS healthcare staff, their local occupational health departmentÌýmay conduct follow-up.

Classification of contacts, follow up advice and public health recommendations for contacts of MERS casesÌý

The classification of contacts, follow up advice and public health recommendations are outlined in theÌýcontact tracing matrix, below.

Advise contacts to:Ìý

• follow instructions inÌýtheÌýcontactÌýinformation sheetÌýwith regards to the requirements for self-isolation,Ìýself-monitoring of temperature and symptoms
• ifÌýsymptomaticÌý(as outlined in the contact information sheet), phone designated contact immediatelyÌý(category 3Ìýhigh exposureÌýcontacts only)Ìý
• if any delay inÌýcontactingÌýthe UKHSA designated contact, phone NHS 111, and state that they have been exposed toÌýMERS-CoV
• if seriously ill, dial 999, again reporting contact withÌýMERS-CoVÌý

Information for contacts of MERS-CoV casesÌý

Contacts who become symptomatic within 14 days of their relevant exposure should be managed as possible cases, with the appropriateÌýclinical assessmentÌýandÌýpublic health actionsÌýcarried out.