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Initial assessment and management of individuals who may be infected with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) or influenza A(H7N9) virus

This guideline is intended for health care workers (HCW) to assist in the management of a person who may be infected with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) or avian influenza A(H7N9) virus. This guideline includes Screening, Assessment, Treatment, Testing and Reporting phases. Each of the phases has key questions or indicators that determine whether the HCW should move on to the next phase, and considerations for infection control.

1. Screening

Screening is conducted upon arrival to the healthcare setting. The following are key components that staff should screen for, upon receiving an individual into the healthcare setting:

Does the patient have a new or worsening cough or shortness of breath and fever Footnote 1?

  • If yes, initiate droplet and contact precautions Footnote 2.
  • The HCW should wear facial protection, gloves and a long-sleeved gown when within 2 metres of the patient. Hand hygiene should be performed prior to entering and when leaving the patient care environment.
  • If no, proceed with usual assessment following Routine Practices and any additional & appropriate precautions required Footnote3.

2. Assessment

A more detailed assessment of risk and exposure should be conducted by a designated HCW, if the screening indicates a possible risk of infection.

Exposure risk assessment:

Within 14 days of illness onset, has the patient:

  • A. Travelled to or resided in:
    • A country where transmission of avian influenza A(H7N9) virus has been confirmed or where H7N9 is known to be circulating in animals Footnote 4? [investigate for H7N9]
    • The Middle East or another MERS-CoV affected country Footnote 4? [investigate for MERS-CoV]
  • B. Had close contact with a confirmed or probable case of MERS-CoV or H7N9; or a traveller or resident with any acute respiratory illness returning from an affected area?

NOTE: Unusual severe acute respiratory illness (SARI) clusters in community or facility settings (and notably involving health care workers) should be appropriately investigated under the direction of local and provincial health authorities.

A close contact is defined as a person who provided care for the patient, including health care workers (except those wearing appropriate PPE), family members or other caregivers, or who had other similarly close physical contact OR who stayed at the same place (e.g. lived with or otherwise had close prolonged contact within two metres) as a probable or confirmed case while the case was ill. For additional details refer to the case definitions Footnote 5.

If ‘yes’ to any exposure question in Assessment:

Recommendations

  • Infection Prevention and Control Footnote 2
    • Routine practices are in place for all patients, at all times, in all healthcare settings.
    • In addition to contact and droplet precautions, airborne precautions should be implemented when performing aerosol-generating medical procedures (AGMPs). A respirator and face/eye protection should be used by all HCWs present in a room where an AGMP is being performed on a patient suspected or confirmed to have MERS-CoV or H7N9 infection.
  • Case and Contact Management
    • Manage cases and contacts according to appropriate jurisdictional or national guidelines Footnote 6.

If ‘no’ to any exposure question in Assessment:

  • Proceed with usual assessment and implement infection prevention and control measures as per Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings Footnote 3.

3. Treatment

If there a patient is positive for A(H7N9) or MERS-CoV, or there is a strong clinical suspicion that they will be, the following are recommended resources to aid clinicians:

  • H7N9: treat with antiviral medication in accordance with the Association for Medical Microbiology & Infectious Disease (AMMI) Canada guidelines for H7N9 Footnote 7
  • MERS-CoV: treat according to established clinical management for supportive care of SARI

4. Testing

Test for pathogen(s) according to Protocol for Microbiological Investigations of Severe Acute Respiratory Infections (SARI) Footnote 8. Follow infection prevention and control guidelines when collecting respiratory specimens Footnote 2. Be aware of approaches in your jurisdiction. For additional details on laboratory testing, refer to the surveillance guidelines Footnote 9.

  • Initial screening tests specific for MERS-CoV can be performed in select laboratories (i.e. primarily provincial public health laboratories); however, such cases are considered probable pending NML confirmation.
  • Laboratories with specimens that screened positive for MERS CoV should forward these to their local public health laboratory (PHL) that can facilitate confirmatory testing at the NML.

5. Reporting

Reporting patients under investigation to public health authorities, in a timely manner, is essential to ensuring a rapid response in the community, if required (e.g. investigating possible contacts and other cases). The following are the recommended steps for HCWs and local public health officials:

  • Clinicians responsible for the investigation of a suspect case of MERS-CoV or A(H7N9) should report cases according to local / provincial / territorial reporting requirements.
  • Provincial / Territorial public health authorities should report confirmed and probable cases of H7N9 and MERS-CoV nationally within 24 hours of their own notification Footnote 10.



Footnote 1

Elderly people and people who are immunocompromised may not have a febrile response to a respiratory infection, so the presence of new onset cough/shortness of breath may be enough to trigger further precautions.

Footnote 2

Interim Guidance - Avian Influenza A (H7N9) Virus - Infection Prevention and Control Guidance for Acute Care Settings

Interim Guidance - Middle East respiratory syndrome coronavirus (MERS-CoV) - Infection Prevention and Control Guidance for Acute Care Settings

Footnote 3

Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare SettingsExternal Link

Footnote 4

Affected Areas Avian Influenza A(H7N9) and MERS-CoV

Footnote 5

Case Definitions MERS-CoV

Case Definitions Influenza A(H7N9)

Footnote 6

Public Health management of human illness associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

Public Health Management of human illness associated with avian influenza A (H7N9)

Footnote 7

Interim Guidance for Antiviral Prophylaxis and Treatment of Influenza Illness due to Avian Influenza A(H7N9) VirusExternal Link

Footnote 8

Laboratory Guidelines - Protocol for Microbiological Investigations of Severe Acute Respiratory Infections (SARI)

Footnote 9

National Surveillance Guidelines for Human Infection with Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

National Surveillance Guidelines for Human Infection with Avian Influenza A (H7N9)

Footnote 10

Emerging Respiratory Pathogens and Severe Acute Respiratory Infection(SARI) Case Report Form