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Public Health management of human illness associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV): Interim guidance for containment when imported cases with limited human-to-human transmission are suspected/confirmed in Canada

Table of Contents

The Public Health Agency of Canada, in collaboration with provincial/territorial public health authorities and other relevant federal government departments, has developed this document to provide guidance to public health authorities working at the federal/provincial/territorial (F/P/T) level in the event that a case of human disease caused by Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is identified within their jurisdictions.

The trigger for this guidance is a novel coronavirus causing human cases with limited human-to-human transmission detected somewhere in the world. This guidance would be used when a case of MERS-CoV infection is suspected or confirmed in Canada.

The strategy outlined in this guidance is containment (i.e. to reduce opportunities for transmission to contacts). This guidance remains relevant while the outbreak management objective is containment and the virus is not transmitting efficiently from person to person.

This guidance is based on current available scientific evidence and expert opinion and is subject to change as new information on transmissibility and epidemiology becomes available. It should be read in conjunction with relevant P/T and local legislation, regulations and policies. This document has been developed based on the Canadian situation and therefore may differ from guidance developed by other countries.

Human illness caused by MERS-CoV was first reported to the World Health Organization (WHO) by the United Kingdom on September 22, 2012. Although cases have been reported in several countries, all cases have been linked to points of origin within Middle East countries. Sustained human-to-human transmission has not been demonstrated; however, some of the infections have occurred in clusters of close contacts or in health care settings, suggesting limited human-to-human transmission. For information regarding the Agency’s current public health risk assessment associated with this illness, please see the Agency’s Summary of Assessment of Public Health Risk to Canada Associated with Middle East Respiratory Syndrome Coronavirus. (Footnote 1)

The Public Health Measures Working Group (PHMWG), an F/P/T working group reporting to the F/P/T Respiratory Infection Disease Outbreak Investigation Coordinating Committee, was convened to develop recommendations for the public health case and contact management of human cases of MERS-CoV infection. In developing this guidance, the PHMWG worked closely with the Influenza and other Respiratory Infectious Diseases F/P/T Working Group (for surveillance-related issues) and the Infection Prevention and Control Expert Working Group, and consulted relevant guidance (i.e. the Agency’s risk assessment and the WHO (Footnote 2)). Guidance developed for previous outbreaks (e.g. the 2003 Severe Acute Respiratory Syndrome outbreak and the 2009 H1N1 influenza pandemic) was reviewed as was available relevant literature.

Case Management
The Agency has developed interim case definitions for human disease caused by MERS-CoV (Footnote 3), specifically for confirmed cases, probable cases and persons under investigation (PUI), as well as associated reporting requirements. The public health management of confirmed cases, probable cases and persons under investigation is outlined below.

(confirmed, probable and PUI cases)

Case management

  • At this time, there is no specific treatment targeting the virus. However, many of the symptoms caused by this virus can be managed; therefore, treatment should be based on the symptoms of the patient.
  • Conduct active daily monitoring of the individual’s health status for duration of illness or until laboratory investigation has ruled out MERS-CoV infection.
  • Provide, as required, information regarding:
    • illness care in the home
    • when/where to go for medical assessment, and instruct case to report travel history or contact history immediately upon presenting to a health care setting
    • prevention of illness transmission (see infection prevention and control section below).

Laboratory testing

  • Facilitate laboratory testing in consultation with the provincial Public Health Laboratory (PHL).
  • As per relevant laboratory guidance and identified protocols, ensure that appropriate specimens from a PUI are forwarded to the respective PHL. The PHL will then coordinate the submission of specimens to the National Microbiology Laboratory for confirmatory testing. Include exposure/travel history with specimens being sent. Refer to Protocol for Microbiological Investigations of Severe Acute Respiratory Infections (SARI) (Footnote 4) for details.

Infection prevention and control

  • Acute health care setting: consult Interim Guidance Middle East respiratory syndrome coronavirus (MERS-CoV): Infection Prevention and Control Guidance for Acute Care Settings. (Footnote 5)
  • In general, cases of MERS-CoV should be managed in hospital to ensure effective isolation and appropriate monitoring of illness.
  • In the event that a case is being managed in the home setting (e.g. in situations where hospitalization is not feasible, or the patient is not ill enough to require hospitalization), the following is recommended:
  • Home care: in addition to routine practices, healthcare workers visiting in the home should use contact and droplet precautions, including a surgical/procedure mask and eye protection, when within two metres of the ill person. It is recommended that aerosol-generating medical procedures should not be carried out in the home setting.
  • For patients, their caregivers and others in the living environment:
    • The ill person should self-isolate while ill and not go to work, school or other public areas until symptoms have resolved and the person is feeling well enough to resume normal activities.
    • If direct contact care must be provided to the ill person, have the ill person cover his or her mouth and nose with tissues or a surgical/procedure mask. Discard tissues and disposable materials used to cover the nose or mouth, preferably in a plastic-lined, covered garbage can. Clean soiled cloths appropriately.
    • The caregiver providing direct contact care to the ill person should wear a procedure/surgical mask and eye protection when within two metres of the ill person and perform hand hygiene after contact.
    • Direct contact with body fluids, particularly oral or respiratory secretions and stool, should be avoided. Use disposable gloves to provide oral or respiratory care, if possible. Perform hand hygiene following all contact.
    • If the ill person cannot be separated from others, then the ill person should wear a surgical/procedure mask or cover his or her nose and mouth with tissues, if possible, while others are in the same room.
    • All members of the household should perform good respiratory etiquette and hand hygiene practices, which are described at FIGHTFLU.CA.
    • Hand washing with plain soap and water is the preferred method of hand hygiene in the community, since the mechanical action is effective at removing visible soil and microbes. Where hand washing is not possible, use of alcohol- based hand rubs (with at least 60% alcohol) is recommended; however, alcohol-based hand rubs alone may not be effective at eliminating virus on hands that are visibly soiled.
    • Shared spaces (e.g. kitchens, bathrooms) should be kept well ventilated (e.g. open windows).
    • Anyone who is at high risk for complications from infection should not care for or come in close contact with the ill person. This may include people with chronic diseases, people who are immunocompromised and seniors.
    • Other types of possible exposure to the ill person or contaminated items should be avoided. For example, avoid sharing toothbrushes, cigarettes, eating utensils, drinks, towels, washcloths or bed linen. Dishes and eating utensils should be cleaned with soap and water after use.
    • High-touch areas such as toilets and bedside tables should be cleaned daily using regular household cleaners or diluted bleach (one part bleach to nine parts water); clothes and bedclothes of ill persons can be cleaned using regular laundry soap and water.
    • Persons caring for an ill family member should limit their contact with other people as much as possible and monitor themselves for any signs of illness.


  • The Agency’s Office of Border Health Services will be involved in the reporting and case management of arriving or departing international passengers who may be PUIs, with the Quarantine Officer notifying local public health authorities should such situations arise. Quarantine officers have no authority over domestic flights. Agency environmental health officers will provide information to the operator regarding the cleaning of the conveyance.

Contact Investigation and Management
Considering the identified trigger and associated objective for this guidance, it is expected that a reasonable effort will be put forth to identify close contacts of confirmed and probable cases occurring in Canada. The purpose of contact tracing for close contacts of confirmed and probable cases are:

  • to better understand the epidemiology of this novel virus;
  • to identify any symptomatic contacts; and
  • to reduce the amount of time between the onset of illness and case isolation in order to reduce the opportunity for transmission to others.

Note: should the contact develop symptoms within 14 days following last close contact with the case, the individual should be managed as a PUI.

A close contact is defined as a person:

  • who provided care for the patient, including health care workers, family members or other caregivers, or who had other similarly close physical contact;


  • 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.

(of probable and confirmed cases)

Contact management

  • Quarantine is not recommended for close contacts at this time.
  • Active monitoring conducted by public health staff, ensuring that these individuals are contacted daily for the duration of the monitoring period, which is defined as 14 days from the last close contact.

Public health advice

  • Advise close contact of case, for 14 days following the last close contact or until the probable case no longer meets the case definition (e.g. the laboratory investigation has ruled out MERS-CoV infection), to:
  • Self-monitor for the appearance acute respiratory illness, including fever and cough.
  • Consider staying in an area where health care is readily accessible, if possible.
  • Maintain good respiratory etiquette and hand hygiene practices as described at FIGHTFLU.CA.
  • If sharing living arrangements with a non-hospitalized case, avoid close contact as much as possible and follow relevant advice provided under the case management section above.
  • Should symptoms develop, self-isolate as quickly as possible and contact the local public health authority for further direction.


  • Considering the uncertainties in determining the transmission efficiency of MERS-CoV, contact tracing should occur for confirmed cases on an aircraft, irrespective of the flight time, if the case travelled while symptomatic. As a priority, those passengers in the same row as the case, as well as passengers in the three rows in front and three rows behind the case, as well as crew members who might have been assigned to care for the case on board the aircraft, should be followed up. Where feasible, public health authorities may consider contact tracing all passengers on the aircraft. The Office of Border Health Services can assist in obtaining passenger flight manifests for international and domestic flights.

References and Additional Resources

Footnote 1
Public Health Agency of Canada. Summary of Assessment of Public Health Risk to Canada Associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV). [Online] [Accessed: 06 24, 2013.]
Footnote 2
World Health Organization. Coronavirus Infections. Global Alert and Response. [Online] 2013. [Accessed: 06 24, 2013.]
Footnote 3
Public Health Agency of Canada. National Interim Case Definition - Middle East respiratory syndrome coronavirus (MERS-CoV). [Online] 2013. [Accessed: 06 24, 2013.]
Footnote 4
Canadian Public Health Laboratory Network. PROTOCOL FOR MICROBIOLOGICAL INVESTIGATIONS OF SEVERE ACUTE RESPIRATORY INFECTIONS (SARI). Canadian Public Health Laboratory Network. [Online] 2012. [Accessed: 05 30, 2013.]
Footnote 5

Public Health Agency of Canada. Interim Guidance - Middle East respiratory syndrome coronavirus (MERS-CoV): Infection Prevention and Control Guidance for Acute Care Settings. [Online] 2013. [Accessed: 06 24, 2013.]

Footnote 6
World Health Organization. INTERIM GUIDANCE DOCUMENTClinical management ofsevere acute respiratory infectionswhen novel coronavirus is suspected:What to do and what not to do. [Online] February 11, 2013.
Footnote 7
European Centre for Disease Prevention and Control. Coronavirus infections: Middle east respiratory syndrome coronavirus . [Online] [Accessed: 06 24, 2013.]
Footnote 8
Public Health England. MERS-CoV Investigation and Management. [Online] 2013. [Accessed: 06 24, 2013.]