Missouri Department of Health & Senior Services Health Advisory 2013

2013·1.5 MB·English

by  Missouri Department of Health and Senior Services

Missouri Department of Health & Senior Services

Healt h Health Advisory

January 11, 2013
Advis ory:
FROM: GAIL VASTERLING
ACTING DIRECTOR
CCoonnssuummppttiioonn ooff

LLooccaallllyy--PPrroodduucceedd,, RRaaww
SUBJECT: Consumption of Locally-Produced, Raw
((UUnnppaasstteeuurriizzeedd)) DDaaiirryy
(Unpasteurized) Dairy Products Contaminated With
PPrroodduuccttss CCoonnttaammiinnaatteedd
Shiga-Toxin Producing Organisms (STEC)
WWiitthh SShhiiggaa--TTooxxiinn

PPrroodduucciinngg OOrrggaanniissmmss
The Missouri Department of Health and Senior Services (DHSS) has become aware
((SSTTEECC))
of several cases of diarrheal illness from northwest Missouri, possibly caused by

January 11, 2013 Shiga-toxin producing Escherichia coli (STEC), including one confirmed as E. coli
O103. These may be related to the consumption of locally-produced, raw
This document will be updated as new (unpasteurized) dairy products.
information becomes available. The

current version can always be viewed
DHSS recommends that any person who has signs or symptoms of STEC infection
at http://www.health.mo.gov
seek medical care. Health care providers should evaluate patients adequately to
The Missouri Department of Health &
determine if testing for STEC infection is warranted.
Senior Services (DHSS) is now using
4 types of documents to provide
important information to medical and Symptoms of STEC infection include severe stomach cramps, diarrhea (which is
public health professionals, and to
often bloody), and vomiting. If there is fever, it usually is not very high. Most
other interested persons:
patients' symptoms improve within 5–7 days, but some patients go on to develop
Health Alerts convey information
hemolytic uremic syndrome (HUS), usually about a week after the diarrhea starts.
of the highest level of importance
which warrants immediate action or The classic triad of findings in HUS are acute renal damage, microangiopathic
attention from Missouri health hemolytic anemia, and thrombocytopenia.
providers, emergency responders,

public health agencies, and/or the
Use of antibiotics in patients with suspected STEC infections is not recommended
public.
until complete diagnostic testing can be performed and STEC infection is ruled out.
Health Advisories provide
Some studies have shown that administering antibiotics in patients with STEC
important information for a specific
incident or situation, including that infections might increase their risk of developing HUS. However, clinical decision
impacting neighboring states; may not
making must be tailored to each individual patient. There may be indications for
require immediate action.
antibiotics in patients with severe intestinal inflammation if perforation is of

Health Guidances contain
concern.
comprehensive information pertaining

to a particular disease or condition,
and include recommendations, Guidelines to optimize detection and characterization of STEC infections include
guidelines, etc. endorsed by DHSS. the following:

Health Updates provide new or
updated information on an incident or  All stools submitted for testing from patients with acute community-acquired
situation; can also provide informa-
diarrhea should be cultured for STEC O157:H7. These stools should be
tion to update a previously sent
simultaneously assayed for non-O157 STEC with a test that detects the Shiga
Health Alert, Health Advisory, or
Health Guidance; unlikely to require toxins or the genes encoding these toxins.
immediate action.
__________________________________  Clinical laboratories should report and send E. coli O157:H7 isolates and

Office of the Director
Shiga toxin-positive samples to the Missouri State Public Health Laboratory
912 Wildwood
(MSPHL) as soon as possible for additional characterization.
P.O. Box 570
Jefferson City, MO 65102
 Specimens or enrichment broths in which Shiga toxin or STEC are detected,
Telephone: [phone]
Fax: [phone] but from which O157:H7 STEC isolates are not recovered, should be forward-
Web site: http://www.health.mo.gov ed as soon as possible to MSPHL so that non-O157:H7 STEC can be isolated.
2

 It is often difficult to isolate STEC in stool by the time a patient presents with HUS.
Immunomagnetic separation (IMS) has been shown to increase recovery of STEC from HUS
patients. For any patient with HUS without a culture-confirmed STEC infection, stool can be
sent to the Centers for Disease Control and Prevention (CDC) through MSPHL. In addition,
serum can be sent to CDC through MSPHL for serologic testing of common STEC serogroups.

The benefits of adhering to the recommended testing strategy include early diagnosis, improved
patient outcome, and detection of all STEC serotypes.

Medical providers are required to report, within one day, suspected or diagnosed cases of the
following: Shiga toxin-producing E. coli (STEC), other Shiga toxin-positive organisms that have not
been characterized, and all cases of post-diarrheal HUS. Reports can be made to the local public
health agency, or to DHSS at 800/392-0272 (24/7). In addition, laboratories are required to submit
isolates or specimens positive for E. coli O157:H7, or for other Shiga toxin-positive organisms, to
MSPHL for epidemiological or confirmation purposes.

Laboratory consultation is available from MSPHL by calling 573/751-3334, or 800/392-0272 (24/7).
Other questions should be directed to DHSS’ Bureau of Communicable Disease Control and
Prevention at 573/751-6113, or 800/392-0272 (24/7).
Missouri Department of Health & Senior Services

Healt h Health Advisory

January 16, 2013
Advis ory:

FROM: GAIL VASTERLING

ACTING DIRECTOR
2012-2013 Seasonal

Influenza Activity in SUBJECT: 2012-2013 Seasonal Influenza Activity in Missouri
Missouri
The Missouri Department of Health and Senior Services (DHSS) has upgraded
influenza activity in Missouri to “widespread” as of the first week of January 2013.
Recent surveillance data suggests a possible shift in influenza activity in
January 16, 2013
Missouri from predominantly influenza B to increasing influenza A activity.

This document will be updated as new Nationally, for the week ending January 5, 2013, of laboratory-confirmed influenza
information becomes available. The cases, approximately 80% were due to Influenza A and 20% to Influenza B. In
current version can always be viewed
Missouri, from week 40 (week ending October 5, 2012) through week 52 (week
at http://www.health.mo.gov
ending December 29, 2012), of influenza-positive specimens at the Missouri State
The Missouri Department of Health &
Public Health Laboratory (MSPHL), 92.1% were due to Influenza B and 15.7% to
Senior Services (DHSS) is now using
4 types of documents to provide Influenza A. However, within the past two weeks that pattern has changed, and
important information to medical and during this period, 78.6% of influenza-positive specimens at MSPHL were due to
public health professionals, and to
Influenza A and 21.4% due to Influenza B.
other interested persons:

Health Alerts convey information
So far this year, the relative disease burden from influenza in Missouri has been
of the highest level of importance
which warrants immediate action or smaller than that seen in many other states. This could be partly explained by the
attention from Missouri health overwhelming predominance of influenza B in the state. If influenza A activity in
providers, emergency responders,
Missouri continues to increase, more demand for health care services would be
public health agencies, and/or the
public. expected since influenza A tends to cause more severe illness than influenza B.

Health Advisories provide
According to Missouri’s sentinel influenza surveillance network, the proportion of
important information for a specific
incident or situation, including that patient visits to physician offices for influenza-like illness (ILI)* has increased over
impacting neighboring states; may not
a one-week period from 5.60% to 5.73% for the week ending January 12, 2013,
require immediate action.
which is above Missouri’s influenza season baseline of 1.66%. At the same time,

Health Guidances contain
syndromic surveillance (ESSENCE) data indicate the proportion of patients with
comprehensive information pertaining
ILI chief complaints in emergency departments (EDs) has shown a one-week
to a particular disease or condition,
and include recommendations, increase from 3.3% to 3.57%. This remains below Missouri’s influenza season
guidelines, etc. endorsed by DHSS. threshold of 4.1%.

Health Updates provide new or
updated information on an incident or The percentage of patients hospitalized (following ED visits) for influenza and/or
situation; can also provide informa-
pneumonia syndromes has generally been increasing statewide over the last four
tion to update a previously sent
weeks, although during the most recent week, decreases were seen in some age
Health Alert, Health Advisory, or
Health Guidance; unlikely to require groups. The most affected group comprises people ≥65 years and there is a steady
immediate action.
increase in hospitalizations in the 0-4 year age group. While DHSS cannot predict
__________________________________
the future number of influenza cases reported or the future percentage of ED visits
Office of the Director for ILI, historically an increase in ED visits for ILI correlates with an increase in
912 Wildwood reported influenza cases within 2-3 weeks.
P.O. Box 570
Jefferson City, MO 65102 Missouri has no reported influenza-associated pediatric deaths in the current season.
Telephone: [phone]
Two school closures due to influenza were reported last week compared to a total of
Fax: [phone]
five since the start of the current flu season.
Web site: http://www.health.mo.gov
2

The single best way to protect against influenza is to get vaccinated each year. It is still not too
late to receive the vaccine.

Guidance:

 Vaccination is recommended for as long as influenza viruses are circulating. It takes about two
weeks after vaccination for antibodies to develop in the body that provide protection against
influenza. Findings from early data suggest that this season’s vaccine so far is reducing the risk
of having to go to the doctor for influenza by about 60% for vaccinated people. The data are
published in “Early Estimates of Seasonal Influenza Vaccine Effectiveness - United States,
January 2013,” in the January 11, 2013, Morbidity and Mortality Weekly Report (MMWR).

 Currently there is no shortage of influenza vaccine in Missouri.

 According to the Centers for Disease Control and Prevention (CDC), the majority of currently
circulating influenza viruses in the U.S. are susceptible to the neuraminidase inhibitor antiviral
medications oseltamivir and zanamivir. Antiviral treatment with oseltamivir or zanamivir is
recommended as early as possible for patients with confirmed or suspected influenza who have
severe, complicated, or progressive illness; who require hospitalization; or who are at greater
risk for serious influenza-related complications. Additional information is available at
http://www.cdc.gov/flu/antivirals/index.htm.

For additional information on Missouri influenza data, go to:
http://health.mo.gov//living/healthcondiseases/communicable/influenza/reports.php

Links to comprehensive information and guidance for medical professionals on seasonal
influenza are available on DHSS’ Web site at:
http://health.mo.gov/emergencies/ert/med/seasonal.php

Additional questions should be directed to DHSS’ Bureau of Communicable Disease Control
and Prevention at 573/751-6113, or 800/392-0272 (24/7)

*ILI is defined as a fever (temperature ≥ 100°F [37.8°C] oral or equivalent) and cough and/or a sore throat in
the absence of a KNOWN cause other than influenza.
Missouri Department of Health & Senior Services

Healt h Health Advisory

May 10, 2013
Advis o ry:

FROM: GAIL VASTERLING

ACTING DIRECTOR
Avian Influenza A

(H7N9)
SUBJECT: Avian Influenza A (H7N9)

Avian Influenza A (H7N9) virus is one of a subgroup of influenza viruses that
normally circulate among birds. Until recently, this virus had not been seen
May 10, 2013
in people. However, human infections have now been detected, and the

resulting disease is of concern because most of the cases have been

This document will be updated as new severely ill. Although no cases of avian influenza A (H7N9) have been
information becomes available. The identified in the United States, clinicians should consider the diagnosis of
current version can always be viewed
avian influenza A (H7N9) virus infection in persons with acute respiratory
at http://www.health.mo.gov
illness compatible with influenza and relevant exposure history. If a patient

The Missouri Department of Health & meets the criteria described below, the Missouri Department of Health and
Senior Services (DHSS) is now using
Senior Services (DHSS) should be immediately contacted regarding
4 types of documents to provide
specimen collection and facilitation of confirmatory testing. Specific
important information to medical and
public health professionals, and to treatment and infection control guidelines (see below) have been issued
other interested persons: which should be instituted whenever a case is first suspected.

Health Alerts convey information
of the highest level of importance As of May 6, 2013, health officials in China report total of 130 human cases of avian
which warrants immediate action or influenza A (H7N9), 31 of them (24%) fatal. Recent analysis of H7N9 human cases
attention from Missouri health
revealed that the median age of patients with confirmed infection is 61 years, and most are
providers, emergency responders,
male (71%). Among the 71 cases for which complete data are available, 54 (76%) had at
public health agencies, and/or the
least one underlying health condition. Most of the confirmed cases involved severe
public.
respiratory illness. Of 82 confirmed cases for which data were available as of April 17, 81
Health Advisories provide (99%) required hospitalization. Among those patients hospitalized, 17 (21%) died of acute
important information for a specific
respiratory distress syndrome (ARDS) or multiorgan failure, 60 (74%) remained
incident or situation, including that
hospitalized, and only four (5%) had been discharged. However, although the majority of
impacting neighboring states; may not
H7N9 cases have resulted in severe respiratory illness in adults, infection with this virus
require immediate action.
may cause mild illness in some, and may cause illness in children as well.

Health Guidances contain
comprehensive information pertaining Cases have been confirmed in eight contiguous provinces in eastern China, two
to a particular disease or condition, municipalities (Beijing and Shanghai), and Taiwan. No cases of avian influenza A
and include recommendations,
(H7N9) have been identified to date in the United States.
guidelines, etc. endorsed by DHSS.

Health Updates provide new or The source of the human infections remains under investigation. H7N9 has been detected
updated information on an incident or in Chinese poultry. While the investigation is ongoing, the current working assumption is
situation; can also provide informa- that most people have been infected with the virus after having contact with infected poultry
tion to update a previously sent
or contaminated environments. A New England Journal of Medicine (NEJM) article
Health Alert, Health Advisory, or
authored by Chinese public health officials released on April 24, 2013 reports that 77% of
Health Guidance; unlikely to require
the first 82 H7N9 patients had some animal exposure.
immediate action.
__________________________________
Almost all confirmed cases have been sporadic, with no epidemiologic link to other human
cases. However, at least three family clusters of two or three confirmed cases have been
Office of the Director
reported where limited human-to-human transmission might have occurred. Epidemiologic
912 Wildwood
investigations have yielded no conclusive evidence of sustained human-to-human
P.O. Box 570
transmission. According to the CDC, H7N9 virus in its current form cannot start a
Jefferson City, MO 65102
pandemic, but it could if the virus mutates to gain the ability to spread readily from person
Telephone: [phone]
to person. At this time, it is impossible to predict what next steps the H7N9 virus may take.
Fax: [phone]

Web site: http://www.health.mo.gov
2

Testing
CDC has developed an rRT-PCR Emergency Use Authorization (EUA) test for public health
laboratories to specifically detect the avian influenza A (H7N9) virus (see fact sheet links below).
This test is only for use on patients with the following clinical and epidemiologic criteria:
A patient with illness compatible with influenza meeting either of the following exposure criteria
and for whom laboratory confirmation is not known or pending, or for whom test results do not
provide a sufficient level of detail to confirm novel influenza A virus infection.

 A patient who has had recent travel (within ≤ 10 days of illness onset) to a country where
human cases of novel influenza A (H7N9) virus have recently been detected or where novel
influenza A (H7N9) viruses are known to be circulating in animals.

OR

 A patient who has had recent contact (within ≤ 10 days of illness onset) with a confirmed or
probable case of infection with novel influenza A (H7N9) virus.

A confirmatory test for influenza A(H7N9) would still be performed at CDC at this time.

These testing eligibility criteria are strictly enforced in order to preserve limited available
testing resources and to support only those appropriate investigations that facilitate successful
public health interventions and surveillance.

Medical providers caring for a patient who meets these criteria should immediately contact
DHSS at 800-392-0272 (24/7) to discuss sending specimens for testing at the Missouri State
Public Health Laboratory (MSPHL). Note that before any specimen is sent to MSPHL, DHSS
staff must first be consulted. After consultation and determination that the patient meets the
criteria for testing, contact the MSPHL at 573-751-3334 or 800-392-0272 for guidance on
specimen collection and shipping prior to collecting the specimens. This will help ensure that
proper specimens are obtained in the right quantity, and that they are packed and transported
properly.

Treatment

Because of the potential severity of illness associated with avian influenza A (H7N9) virus
infection, the Centers for Disease Control and Prevention (CDC) recommends that all H7N9
patients (confirmed, probable, or under investigation for H7N9 infection) receive antiviral
treatment with oseltamivir or zanamivir as early as possible. Treatment should be initiated even
>48 hours after onset of illness. Treatment should not be delayed for laboratory confirmation of
influenza or H7N9 infection. Note that amantadine and rimantadine are not recommended for
treatment of H7N9 virus infection. Current guidance on treatment is available from CDC at:
http://www.cdc.gov/flu/avianflu/h7n9-antiviral-treatment.htm. Be aware that this guidance may
change over time as more experience is gained in treating H7N9 infections.
3

Infection Control

Guidance on initial infection control in healthcare settings for confirmed, probable, or cases
under investigation for avian influenza A (H7N9) is available from CDC at:
http://www.cdc.gov/flu/avianflu/h7n9-infection-control.htm. These infection control measures
should be instituted immediately whenever a case is first suspected. Note that this guidance
recommends a higher level of infection control measures than for seasonal influenza. Among
important differences from the seasonal influenza guidance are recommendations for contact and
airborne precautions for patients with confirmed, probable, or a cases under investigation of H7N9
virus infection, which includes a higher level of personal protective equipment for healthcare
personnel, including eye protection (i.e., required) and the expanded use of respirators (i.e., for all
patient-care activities). Also note that this interim guidance adds to existing infection control
precautions (i.e., Standard Precautions) used every day in healthcare settings during the care of any
patient. As with the treatment guidelines, guidance on infection control may be updated as more
information on influenza A (H7N9) becomes available.

Vaccination

Past serologic studies evaluating immune response to H7 subtypes of influenza viruses have shown
no existing cross-reactive antibodies in human sera. In the United States, planning for H7N9 vaccine
clinical trials is under way. Although no decision has been made to initiate an H7N9 vaccination
program in this country, CDC recommends that local authorities and preparedness programs take
time to review and update their pandemic influenza vaccine preparedness plans because it could take
several months to ready a vaccination program, if one becomes necessary.

Information on where influenza A (H7N9) cases are occurring is available from WHO at:
http://www.who.int/influenza/human_animal_interface/influenza_h7n9/Data_Reports/en/index.html.

Influenza A (H7N9) information and recommendations for travelers is available from CDC at:
http://wwwnc.cdc.gov/travel/notices/watch/avian-flu-h7n9.htm. This material will be updated as
necessary.

Fact Sheet for Healthcare Providers: Interpreting CDC Human Influenza Virus Real-Time RT-PCR
Diagnostic Panel Influenza A/H7 (Eurasian Lineage) Assay Test Results at:
http://www.fda.gov/downloads/MedicalDevices/Safety/EmergencySituations/UCM349062.pdf

Fact Sheet for Patients: Understanding Results from the CDC Human Influenza Virus Real-Time RT-
PCR Diagnostic Panel A/H7 (Eurasian Lineage) Assay at:
http://www.fda.gov/downloads/MedicalDevices/Safety/EmergencySituations/UCM349064.pdf

For links to additional information, see DHSS’ Avian Influenza website at:
http://health.mo.gov/emergencies/panflu/avian.php.

Questions should be directed to DHSS’ Bureau of Communicable Disease Control and Prevention at
573/751-6113, or 800/392-0272 (24/7).
Missouri Department of Health & Senior Services

Healt h Health Advisory

June 10, 2013
Advisory:

FROM: GAIL VASTERLING
ACTING DIRECTOR

UUppddaatteedd GGuuiiddeelliinneess
SUBJECT: Updated Guidelines for Evaluation of Severe
ffoorr EEvvaalluuaattiioonn ooff
Respiratory Illness Associated with MERS-CoV
SSeevveerree RReessppiirraattoorryy

IIllllnneessss AAssssoocciiaatteedd
On March 8, 2013, the Centers for Disease Control and Prevention (CDC) issued, and
wwiitthh MMEERRSS--CCooVV
the Missouri Department of Health and Senior Services (DHSS) forwarded, a CDC
Health Advisory entitled “Notice to Health Care Providers: Updated Guidelines for
Evaluation of Severe Respiratory Illness Associated with a Novel Coronavirus.” On
June 7, 2013, CDC provided updated epidemiological information on, and evaluation
guidelines for, what is now called Middle East Respiratory Syndrome Coronavirus
June 10, 2013 (MERS-CoV). This Health Advisory contains the new information and guidelines from
CDC. If a patient meets the criteria described below, DHSS should immediately be
This document will be updated as new contacted regarding specimen submission and facilitation of testing.
information becomes available. The

current version can always be viewed
at http://www.health.mo.gov CDC HEALTH UPDATE
Distributed via the CDC Health Alert Network
The Missouri Department of Health &
June 7, 2013
Senior Services (DHSS) is now using
4 types of documents to provide CDCHAN-00348
important information to medical and
public health professionals, and to Notice to Health Care Providers: Updated Guidelines for Evaluation
other interested persons: of Severe Respiratory Illness Associated with

Health Alerts convey information Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
of the highest level of importance
which warrants immediate action or Summary: The Centers for Disease Control and Prevention (CDC) is working closely with the
attention from Missouri health
World Health Organization (WHO) and other partners to better understand the public health
providers, emergency responders,
risk posed by Middle East Respiratory Syndrome Coronavirus (MERS-CoV), a novel corona-
public health agencies or the public.
virus that was first reported to cause human infection in September 2012. No cases have been
Health Advisories provide
reported in the United States. The purpose of this HAN Advisory is to provide updated
important information for a specific
guidance to state health departments and health care providers in the evaluation of patients for
incident or situation, including that
impacting neighboring states; may not MERS-CoV infection including expansion of availability of laboratory testing and, in consulta-
require immediate action. tion with WHO, expansion of the travel history criteria for patients under investigation from

Health Guidances contain within 10 to 14 days for investigation and modification of the case definition. Please dissemi-
comprehensive information pertaining nate this information to infectious diseases specialists, intensive care physicians, internists,
to a particular disease or condition, infection preventionists, as well as to emergency departments and microbiology laboratories.
and include recommendations,

guidelines, etc. endorsed by DHSS.
Background

Health Updates provide new or
MERS-CoV, formerly called “novel coronavirus,” is a beta coronavirus that was first
updated information on an incident or
described in September 2012, when it was reported to have caused fatal acute lower
situation; can also provide informa-
tion to update a previously sent respiratory illness in a man in Saudi Arabia. Genetic sequence analyses have shown that this
Health Alert, Health Advisory, or new virus is different from other known human coronaviruses, including the one that caused
Health Guidance; unlikely to require
severe acute respiratory syndrome (SARS). Diagnosis relies on testing with real time reverse
immediate action.
transcription polymerase chain reaction (RT-PCR) assays. There is no specific treatment for
__________________________________
MERS-CoV infection; care is supportive.
Office of the Director

912 Wildwood
As of June 7, 2013, 55 laboratory-confirmed cases of MERS-CoV infection have been reported
P.O. Box 570
to WHO—two from France, three from Italy, two from Jordan, two from Qatar, 40 from Saudi
Jefferson City, MO 65102
Arabia, two from Tunisia, one from the United Arab Emirates, and three from the United
Telephone: [phone]
Kingdom (UK). Additional details can be found in the June 7, 2013 MMWR Early Release
Fax: [phone]
(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm62e0607a1.htm?s_cid=mm62e0607a1_w)
Web site: http://www.health.mo.gov
2

To date, all cases have a direct or indirect link to one of four countries: Saudi Arabia, Qatar, Jordan, and the
United Arab Emirates. No cases have been reported in the United States. Illness onsets were from April
2012 through May 2013. Of the 55 cases, 31 were fatal, for a case-fatality rate of 56%. The median age of
cases is 56 years. All of the patients were aged >24 years, except for two children, one aged 2 years and one
aged 14 years.

Eight clusters of illnesses have been reported by six countries (France, Italy, Jordan, Saudi Arabia, Tunisia,
and UK). These clusters provide clear evidence of human-to-human transmission of MERS-CoV. The largest
cluster reported to date consists of 25 cases, 14 of which were fatal, associated with a health-care facility in
Al-Ahsa governorate in Saudi Arabia. Two of the case-patients in that cluster were health-care personnel who
acquired the infection after exposure to patients with confirmed MERS-CoV infection.

The first case reported by France was in a person with an underlying immunosuppressive condition who
initially had abdominal pain and diarrhea and subsequently developed respiratory complications. This case
raises the possibility that presentations may not initially include respiratory symptoms. Among cases reported
to WHO in which more detailed information is available, most are reported to have chronic underlying
medical conditions or immunosuppression; such persons may be at increased risk of MERS-CoV infection or
severe disease, or both. In some instances, sampling with nasopharyngeal swabs did not detect MERS-CoV by
PCR; however, MERS-CoV was detected by PCR in lower respiratory tract specimens from those same
patients. Therefore, lower tract respiratory specimens should be a priority for collection and PCR testing, in
addition to nasopharyngeal swabs.

Recommendations

Recommendations and guidance on MERS-CoV case definitions, case investigation, specimen collection and
shipment for testing, and infection control (including use of personal protective equipment) are available at the
CDC MERS website (http://www.cdc.gov/coronavirus/MERS/index.html). Information and guidance posted
on this website may change as we learn more about the virus. Please check CDC’s MERS website regularly
for the most current information. [Questions should be directed to DHSS’ Bureau of Communicable
Disease Control and Prevention at 573/751-6113, or 800/392-0272 (24/7).]

Surveillance
As a result of investigations suggesting incubation periods for MERS CoV may be longer than 10 days, the
time period for considering MERS in persons who develop severe acute lower respiratory illness days after
traveling from the Arabian Peninsula or neighboring countries* has been extended from within 10 days to
within 14 days of travel.

In particular, persons who meet the following criteria for “patient under investigation” (PUI) should be
reported to state and local health departments and evaluated for MERS-CoV infection:

 A person with an acute respiratory infection, which may include fever (≥ 38°C , 100.4°F) and cough;
AND
 Suspicion of pulmonary parenchymal disease (e.g., pneumonia or acute respiratory distress syndrome
based on clinical or radiological evidence of consolidation); AND
 History of travel from the Arabian Peninsula or neighboring countries* within 14 days; AND
 Symptoms not already explained by any other infection or etiology, including clinically indicated tests
for community-acquired pneumonia† according to local management guidelines.

In addition, the following persons may be considered for evaluation for MERS-CoV infection:

 Persons who develop severe acute lower respiratory illness of known etiology within 14 days after
traveling from the Arabian Peninsula or neighboring countries* but who do not respond to appropriate
therapy; OR
3

 Persons who develop severe acute lower respiratory illness who are close contacts‡ of a symptomatic
traveler who developed fever and acute respiratory illness within 14 days of traveling from the
Arabian Peninsula or neighboring countries.*

In addition, CDC recommends that clusters of severe acute respiratory illness (SARI) should be investigated
and, if no obvious etiology is identified, local public health officials should be notified and testing for MERS-
CoV conducted if indicated.

CDC requests that state and local health departments report PUIs for MERS-CoV and clusters of SARI with
no identified etiology to CDC. To collect data on PUIs, please use CDC’s Interim Health Departments MERS-
CoV Investigation Form available at http://www.cdc.gov/coronavirus/mers/guidance.html.

Laboratory Testing
Testing of specimens for MERS-CoV is currently being conducted at CDC. The Food and Drug
Administration (FDA) issued an Emergency Use Authorization (EUA) on June 5, 2013, to authorize the use of
the CDC Novel Coronavirus 2012 Real-time RT-PCR Assay (NCV-2-12 rRT-PCR Assay) to test for MERS-
CoV in clinical respiratory, blood and stool samples. This EUA is needed because, at this time, no FDA-
approved tests that identify MERS-CoV in clinical specimens are available. This assay will be deployed to
Laboratory Response Network (LRN) laboratories in all 50 states over the coming weeks. Updated
information about laboratories with the capacity to conduct MERS testing with the NCV-2-12 rRT-PCR Assay
will be provided on CDC’s MERS website (http://www.cdc.gov/coronavirus/mers/case-def.html).

To increase the likelihood of detecting MERS-CoV, CDC recommends collection of specimens from different
sites-- for example, a nasopharyngeal swab and a lower respiratory tract specimen such as sputum,
bronchoalveolar lavage, bronchial wash, or tracheal aspirate. Specimens should be collected at different times
after symptom onset, if possible. Lower respiratory tract specimens should be a priority for collection and PCR
testing; stool specimens are of lower priority. Specimens should be collected with appropriate infection control
precautions http://www.cdc.gov/coronavirus/mers/case-def.html.

Medical providers caring for a patient who meets the above criteria for a “patient under investigation”
(PUI) should immediately contact DHSS at 800/392-0272 (24/7) to discuss sending specimens for testing.
Note that before any specimen is sent for testing, DHSS staff must first be consulted. After consultation
and determination that the patient meets the criteria for testing, contact the Missouri State Public
Health Laboratory (MSPHL) at 573/751-3334 or 800/392-0272 for guidance on specimen collection and
shipping prior to collecting the specimens. This will help ensure that proper specimens are obtained in
the right quantity, and that they are packed and transported properly.

Case Definitions
The MERS-CoV case definition continues to evolve and is available at http://www.cdc.gov/coronavirus/mers/case-
def.html. In consultation with WHO, the definition of a probable case of MERS has been updated to also include
persons with severe acute respiratory infection with no known etiology with an epidemiologic link to a confirmed
MERS-CoV case.

Infection Control
There is clear evidence of limited human-to-human transmission, possibly involving different modes, such as
droplet and contact transmission, but further studies are required to better understand the risks. Until the
transmission characteristics of MERS-CoV are better understood, patients under investigation and probable
and confirmed cases should be managed in healthcare facilities using standard, contact, and airborne
precautions. As information becomes available, these recommendations will be re-evaluated and updated as
needed.