Guidance for the public health management of MERS-CoV infections
Guidance for Health Protection Teams (HPTs)

Purpose and scope

This document sets out the public health response to Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) infection in Scotland.

It is for use by NHS health protection teams, Public Health Scotland (PHS) and other stakeholders to inform planning and response to MERS-CoV.

This guidance is an update to previous Health Protection Scotland (HPS) guidance and is an adaptation of the UKHSA guidance. Recommendations made are aligned with the UKHSA guidance, adapted for use in Scotland.

This document sits within an existing framework of PHS and NHS board emergency response and incident management and response plans and does not replace these.

Related resources

This guidance should be read with reference to these related resources available on UKHSA information and guidance on MERS-CoV.

Relevant recommendations from these UKHSA guidance documents are provided in this Scottish adaptation, however they may contain additional advice or context that would support decision making.

UKHSA related resources:

• MERS-CoV: public health investigation and management of possible cases, provides case and contact definitions and guidance for public health management of cases and contacts. These are aligned to Scotland.
• MERS-CoV: public health investigation and management of close contacts of confirmed cases, defines the contacts and lists the actions needed to be taken by the HPTs for contact tracing
• Testing for the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in England, describes the process for primary and confirmatory testing of human samples for MERS-CoV in England. These processes are different to Scotland. 
• UKHSA risk assessment of MERS-CoV, provides relevant guidance on risk assessment and advice for travellers to Middle East / Hajj pilgrims.

Additional Scottish guidance:

• National Infection Prevention and Control Manual (NIPCM) A-Z Pathogens
• Management of Public Health Incidents: Guidance on the roles and responsibilities of NHS led incident management teams

Introduction

MERS-CoV is a novel coronavirus that was first identified in 2012.

Symptoms include fever and cough that progress to a severe pneumonia causing shortness of breath and breathing difficulties. In some cases, a diarrheal illness has been the first symptom to appear.

There is currently no vaccine available for MERS-CoV.

MERS-CoV is a high consequence infectious disease (HCID) and requires an enhanced public health response.

Individuals with comorbidities such as diabetes, chronic lung disease, immunocompromise and renal failure are at increased risk of severe illness or death. MERS-CoV has a significant case fatality rate in affected countries, particularly in older adults with comorbidities.

The main risk of MERS-CoV for Scotland is importation from affected countries and secondary transmission. First generation cases diagnosed in the UK will most likely have acquired their MERS-CoV infection in an affected country.

Camels in the Middle East are considered the most common reservoir of the infection and a source of zoonotic infection for humans.

Epidemiological updates can be found at:

At-risk areas

Due to the specific geography of this reservoir, MERS-CoV possible cases are defined by a travel history to an at-risk area or an epidemiological link to a confirmed case.

See case definitions.

Travel advice for people travelling to the at-risk areas can be found on fitfortravel.

When considering the classification of cases, HPTs should consult the current list of at-risk areas in the UKHSA case definition. These are also provided below but may be subject to update and the latest list should be consulted.

There are two levels of at-risk area: A and B.

Area A

The current at-risk area A is:

• Bahrain
• Jordan
• Iraq
• Iran
• Kingdom of Saudi Arabia
• Kuwait
• Oman
• Qatar
• United Arab Emirates
• Yemen

Area B

The current at-risk area B is:

• Kenya

Further travel advice

Travel advice for people travelling to the at-risk areas can be found on the MERS CoV pages of fitfortravel.

Transmission

In addition to zoonotic transmission, MERS-CoV can be spread from person to person through contact with respiratory secretions.

MERS-CoV is classified as an airborne HCID. Airborne HCIDs are spread by respiratory droplets or aerosol transmission, in addition to contact routes of transmission.

MERS-CoV has an incubation period of 2 to 14 days. The risk to contacts of confirmed cases of MERS-CoV infection is low, but contacts should be followed up for 14 days following last exposure.

Cases are considered infectious until they have had two negative MERS-CoV test results on adequate samples, 48 hours apart.

Case definition

Possible case

Note that case definitions are aligned with UKHSA case definitions.

There are three possible case definitions:

Atypical Presentation

Clinicians should be alert to atypical presentations in immunocompromised patients.

Atypical presentation may include absence of fever.

Presumptive case

A presumptive case is a person that has tested positive for MERS-CoV at:

• West of Scotland Specialist Virology Centre (WoSSVC) in Glasgow
• Specialist Virology Centre (SVC) in Edinburgh

A person who has tested positive outside the UK will be treated as a presumptive case and confirmatory testing is recommended at WoSSVC or SVC.

In this scenario, the health boards may also refer samples directly to Respiratory Virus Unit (RVU) UKHSA, Colindale for confirmation.

Confirmed case

A confirmed case is a person that has tested positive for MERS-CoV at the Respiratory Virus Unit (RVU) UKHSA, Colindale.

Notification

Clinicians should notify their HPT of all patients that meet the possible case definition immediately, including out of hours. This should be done without waiting for test results.

HPTs should remind the reporting clinician that MERS CoV is an HCID and direct them to the relevant infection prevention and control resources.

HPTs should immediately notify PHS of all possible case and test results, when available, by phone on 0141 300 1422 (day) or 0141 211 3600 (out of hours) and follow up by email to phs.respiratory@phs.scot

All test results should be communicated immediately by laboratories to the local HPT.

If test results are received for a patient who was not previously notified to the HPT, then case details should be taken, and HPTs should remind the managing clinician of the relevant infection prevention and control resources.

Following notification, public health actions should commence for all cases, as per their classification.

Clinical management

All services assessing possible MERS-CoV should be aware of the HCID status and the relevant infection prevention and control and public health management actions to take to minimise any onward spread, or the need to follow-up additional contacts.

See sections on notification and infection prevention and control.

Patient presentation

Remote assessment of possible MERS-CoV is advised in all settings.

If a possible case has presented in person, provide them with a fluid resistant surgical face mask and place them in a room on their own equipped for remote consultation.

The number of staff in contact with the patient should be kept to a minimum. All staff in contact with the patient should wear appropriate PPE. Contact is defined in public health management of contacts.

Where no single room is available on-site, and it is possible for a patient to safely return home for assessment in private transport or with previously exposed contacts (e.g. another household member), advise them to return home. Follow-up for urgent remote assessment should be completed once they return home.

If immediate clinical care or in-person assessment is required, then don PPE in line with the National Infection Prevention and Control Manual.

Clinical assessment for public health management

Assess the patient against all three possible case definitions.

Primary care or other community settings should discuss the patient with a local infectious disease consultant.

Testing should not take place in primary care or community settings.

Once an initial remote assessment has been made by a healthcare professional against the possible case definition, then full clinical assessment and testing can take place in infectious diseases departments where full HCID PPE is available.

Initial clinical assessment of patient should determine whether they are clinically stable or require immediate care. Dynamic risk assessment will be required where urgent clinical care is required.

Transfer of patient

The clinical team should arrange transfer for further assessment / clinical care.

Minimize contact with the patient and adhere to the National Infection Prevention and Control Manual during the transfer.

Where a patient can travel in their own car, or with previously exposed household contacts, they can self-transfer.

Where the patient cannot maintain isolation during self-transfer, or requires urgent transfer, contact Scottish Ambulance Service to arrange transfer, clearly stating that they are a possible HCID case and that full PPE in line with the National Infection Prevention and Control Manual will be required for all staff involved in the transfer.

Advise the patient and the receiving service of the transfer plan including where to present and who to contact upon arrival.

Post-consultation

After the patient is transferred:

• undertake decontamination of all affected areas in line with the National Infection Prevention and Control Manual
• prepare list of all staff potentially exposed, level of contact with case (distance and time) and details of PPE used
• prepare list of all other people potentially exposed, for example,
  • in waiting rooms
  • in household
  • during travel
• contact your health protection team (HPT) in line with the notification section

Infection prevention and control

Infection prevention and control should be implemented as set out in the National Infection Prevention and Control Manual (NIPCM).

Testing

When to test

Any person meeting the possible case definition should be tested.

As MERS-CoV co-infection with other respiratory pathogens has been reported, possible cases should be tested regardless of other infections being identified.

After discussion with a local infectious disease physician or virologist/microbiologist, the duty/on-call virologist at WoSSVC or SVC should be contacted prior to sending any samples.  

Clinical staff should complete specimen request forms or electronic test ordering systems, and directly communicate with the laboratory.  

Testing pathway

Diagnostic testing is provided by the WoSSVC, Glasgow and the SVC, Edinburgh.

• SVC covers NHS Borders, NHS Lothian and NHS Fife.
• WoSSVC covers all the other health boards in Scotland.

Testing is available 7-days per week including out of hours. Out of hours testing must be discussed with the on-call virologist.

Where parallel testing for other respiratory pathogens is appropriate, use existing arrangements for testing for other common causes of pneumonia. Discuss arrangements for individual cases with the WoSSVC/SVC as required. 

Any further testing in relation to an incident would be undertaken by WoSSVC/SVC.

WoSSVC/SVC will notify the referring laboratory with the results.

The referring laboratory will notify the referring clinician and local HPT.

WoSSVC/SVC will send positive samples to Respiratory Virus Unit, UKHSA at Colindale for confirmation. 

Contact details

West of Scotland Specialist Virology Centre, Glasgow

Specialist Virology Centre, Edinburgh

Sample requirements

Primary testing

The recommended diagnostic sample set is:

• an upper respiratory tract (URT) sample (combined nose and throat viral swabs, or nasopharyngeal aspirate)
  • where possible, URT samples should be collected in molecular sample solution (MSS)
  • if MSS is not routinely used, laboratories should consider holding a small contingency stock of MSS to support rapid testing
• if obtainable, a lower respiratory tract (LRT) sample (sputum, or an endotracheal tube aspirate if intubated)
  • if a LRT sample is not available in the initial sample set, and the patient condition deteriorates, additional samples may be required to formally exclude infection

Samples should be considered infectious and should be handled at containment level 3 (CL-3).

In accordance with the WHO guidance on regulations for the transport of infectious substances 2021-2022, samples from possible cases should be packaged and transported in accordance with Category B UN 3373 regulations.

Those with a positive result from WoSSVC/SVC are a presumptive case of MERS-CoV.

Confirmatory testing

All samples where MERS-CoV is detected at WoSSVC/SVC will be sent to RVU, UKHSA for confirmation. No charge will be made for MERS-CoV confirmatory testing. 

• WoSSVC/SVC will inform RVU UKHSA of intention to refer samples prior to sending the samples
• Phone RVU on 020 8327 6017 or 020 8200 4400 (out of hours) prior to sending samples
• Provide MERS-CoV Ct values on the request form
• Samples should be urgently transported to RVU, UKHSA.

Those with a positive result from RVU are a confirmed case of MERS-CoV.

Those with a positive result from WoSSVC/SVC that receive a negative result from RVU should be discussed by clinicians, HPTs and PHS.

Follow-up samples from positive MERS-CoV cases may be requested by UKHSA including non-respiratory samples. RVU will advise on the types of samples required and where samples should be sent.

In accordance with guidance on regulations for the transport of infectious substances 2021-2022, samples from possible MERS-CoV patients should be packaged and transported in accordance with Category B UN 3373 regulations.

Laboratory safety

Clinical laboratories should perform their own risk assessments for handling biological specimens from patients with suspected or confirmed MERS-CoV.

Clinicians may not have considered MERS-CoV infection as a potential diagnosis, prior to sending specimens to the laboratory. Good laboratory practice, including the use of standard biological safety precautions, regular training of staff, and the use of standard operating procedures, will help minimise potential risks. 

Any procedure that involves potentially infectious material and is associated with a risk of generating aerosols, droplets or splashes, should always be performed within a Microbiological Safety Cabinet (MSC) at containment level 3 (CL-3). Respiratory samples are most likely to contain virus, but there is a possibility that it may be present in other samples including faeces and urine. Once lysis buffer has been added, these samples may be taken out of CL-3 following a local risk assessment. 

For samples in MSS, please note that inactivation studies have been performed for SARS-CoV-2 but not for MERS-CoV.  

End of case follow up period

The end of the infectious period can be defined as two negative MERS-CoV test results on adequate samples, 48 hours apart, however the decision to end isolation should be assessed on a case-by-case basis by the IMT.

Management of asymptomatic cases

Decisions on where care is delivered should be informed by the infection control guidance but also be based on the patient’s clinical needs.

Asymptomatic cases may request or be requested to be discharged home (or to remain at home) before the end of their infectious period.

This may include:

• previously symptomatic cases becoming well enough to be discharged from hospital care but still be PCR positive for MERS-CoV
• asymptomatic contacts diagnosed on respiratory swabbing

Due to the potential risk of infection all the following criteria should be met:

• the individual agrees to isolate at home until the end of their infectious period
• the individual is living alone, away from any other individuals, with use of a private room and separate bathroom and toilet facilities
• the individual agrees not to receive visitors in person
• arrangements are made to monitor the individual’s health daily and to take additional specimens for PCR testing (via personnel with appropriate PPE)
• standby arrangements are made to transport the individual to a healthcare facility in case of development of symptoms, in accordance with infection control guidance

Enhanced surveillance

Follow-up of the cases and contacts by the HPT team is recommended.

A login to the Scottish Health Protection Information Resource (SHPIR) is required to access the questionnaires/forms to be completed which are as follows.

Follow up testing for enhanced surveillance will be decided by the IMT.

All the above forms are to be completed at the appropriate time and returned to PHS by email at phs.respiratory@phs.scot

Public health management of cases

For possible cases

1. Inform PHS on 0141 300 1422 (day) or 0141 211 3600 (out of hours) and follow-up by email phs.respiratory@phs.scot
2. Recommend infection prevention and control measures to clinician and ensure local IPCT is aware.
3. Add the case to HP Zone using the unlisted managed context 'MERS-CoV'.
4. Interview the patient (where possible), healthcare workers, family members and others to compile information about travel history and detail of all community, travel and healthcare contacts. See public health management of contacts.
5. It is not recommended to follow-up contacts of possible cases before primary test results are received (i.e. before they are presumptive cases). Following up contact of possible cases can be considered by the health protection team, based on their confidence in the diagnosis.
6. complete and return the form 1: minimum data set – possible case (SHPIR login required) to phs.respiratory@phs.scot the next working day.

For presumptive positive (and confirmed) cases

1. Inform PHS on 0141 300 1422 (day) or 0141 211 3600 (out of hours) and follow-up by email phs.respiratory@phs.scot
2. Ensure infection prevention and control have been implemented
3. Arrange IMT meeting to be held within 12 hours and communicate details to PHS. Following the reporting of a presumptive or confirmed MERS-CoV case, PHS will consider forming a national IMT chaired by PHS.
4. Follow up all identified contacts and complete any further contact tracing required. See public health management of contacts.
5. Complete and return the form 1a: initial confirmed case report (SHPIR login required) to phs.respiratory@phs.scot

Once the RVU result is received review all public health actions.

Public health management of contacts

Contact tracing should commence for presumptive positive cases.

Effort should be made to identify all people who meet the contact definition during the full infectious period, from onset of symptoms to the current time.

The follow-up of healthcare contacts should be undertaken in collaboration with occupational health and the infection prevention control team, as appropriate.

Summary information should be collated using the contact line list (SHPIR login required).

Contact definitions

Any person who has had the following contact with a symptomatic confirmed (or presumptive positive) case.

Household (or other closed setting) contact

Is defined as:

• prolonged face-to-face contact (more than 15 minutes) in a household or other closed setting.

Active follow-up and quarantine (14 days of self-isolation) are recommended for all household (or other closed setting) contacts.

Health and social care contact

Is defined as:

• healthcare or social care worker who provided direct clinical or personal care, or was in close vicinity of an aerosol generating procedure (AGP)
• inpatients who are exposed to the case due to their close placement in the health or social care setting
• visitor exposed within a health or social care setting

Active follow-up and quarantine (14 days of self-isolation) are recommended for health and social care contacts who were not wearing PPE during all contact.

Passive follow-up is recommended for those who wore PPE during all contact.

It is possible that a healthcare worker may have a mix of exposures, starting without PPE and then switching to use of PPE. In this situation, they should be actively followed up and quarantine for 14 days after the last exposure without PPE.

PPE and AGP are as defined in the National Infection Prevention and Control Manual.

Active follow-up is recommended for inpatients exposed to a case through the hospital trust. It is advisable to cohort or isolate these patients in side-rooms.

Flight contact

Is defined as:

• passengers on the flight who were seated in 3 rows in front and behind the case during the flight
• members of the cabin crew who have had prolonged face-to-face contact (more than 15 minutes) with the case during the flight

If the case is a cabin crew member, then all passengers seated in the area served by the crew member during the flight and all other crew members should be regarded as flight contacts.

Passive follow-up is recommended for all flight contacts.

PHS will lead on flight contact tracing and any notification of national focal points.

Management of contacts

Self-isolation (quarantine) and active follow-up

Self-isolation and active follow-up is recommended for all:

• household (community) contacts
• health and social care contacts without PPE
• patients and visitors exposed in a health or social care setting without PPE

Contacts should be advised to self-isolate at home for 14 days after the last contact with the case.

Health protection teams should:

• explain the risk of infection
• advise on symptoms and actions to take if these develop
• explain how active daily follow-up will be completed
• share contact details for the local HPT

Active daily follow-up is required including a response from the contact confirming they have not developed any MERS CoV symptoms.

This may be available via SMS through HP Zone, or alternatively by daily telephone call to the contact.

Where a contact is a patient that was exposed in the health or social care setting the general practitioner and any care givers for the contact should be advised.

For those contacts who remain in-patients, IPCT should co-ordinate active follow-up to include communication points as above. MERS-CoV-specific infection control advice would not apply unless a contact met the criteria for a possible case.

Any difficulties with quarantine (self-isolation) should be discussed on a case-by-case basis in the local IMT.

Passive follow up

Passive follow-up is recommended for:

• health and social care contacts wearing appropriate PPE as outlined in National Infection Prevention and Control Manual during all contact with the symptomatic case
• flight contacts

Passive follow-up should continue for 14 days after the last contact with the case.

Passive follow-up for health and social care worker contacts should be co-ordinated by occupational health (OH).

Passive follow-up of all other contacts should be co-ordinated by the HPT.

This should include contacting the individual immediately to inform them of:

• low-level risk of transmission of MERS-CoV
• symptom awareness
• actions to take if symptoms arise
• HPT, clinician and emergency contact details

Contacts in passive follow-up can attend work normally without restrictions.

Contacts in passive follow-up should plan any domestic travel to allow for the possibility of seeking medical attention rapidly. This would generally be equivalent to being able to access medical help within one hour.

Transport which cannot be easily exited – for example, flights or ferries – should be limited to approximately one hour at a time. 

Contacts should not travel internationally during their passive follow-up period.

Exclusion and self-isolation are not required.

Flight contact tracing

Imported MERS-CoV cases are likely to have travelled internationally.

Actions are only required if the case had respiratory symptoms while travelling on the aircraft.

Notify PHS of all possible cases who have flown without waiting for test results. This allows PHS to minimise the time to follow-up for flight contacts. Manifest request procedures can take time to complete.

Notify PHS and provide full flight details and seat number. Check whether the case moved seats during the flight, or did not sit in their allocated seat.

In addition to the direct communications to passengers, PHS may release a media statement or send an email message to other passengers seated outside of the 3-row area.

Flight contacts (or other contacts) who are outwith Scotland will be notified to the international health regulations national focal point of relevant country by PHS.

Symptomatic contacts

All contacts (both active and passive follow-up) who report symptoms should be assessed against the case definition of a possible case, see possible case definition three for relevant symptoms.

Those who meet the definition should be managed as possible cases. Follow the process set out in clinical management, advising initial remote consultation with infectious diseases.

If contact has a negative test result, they should continue to follow the previous actions (for example, quarantine and active follow up) until their 14-day follow-up period is complete

Ending contact follow-up

At the end of the follow-up period complete close contact form 2b and email to phs.respiratory@phs.scot.

The IMT will guide the decision for follow up sample and testing requirements.

Incident management

A local IMT should be established to manage any presumptive or confirmed cases.

Refer to the management of public health incidents: guidance on the roles and responsibilities of NHS led incident management teams.

A confirmed case may constitute an incident requiring a national response due to the potential public health impact occurring across regional boundaries and the need for national co-ordination, in accordance with the management of public health incidents: guidance on the roles and responsibilities of NHS led incident management teams.

Communications

NHS health board communication teams should develop local reactive lines for possible cases.

This will likely include media communications to the public, healthcare staff, government and (via international health regulation national focal point) to WHO/ECDC.

Support can be provided by the PHS communications team.

If reactive lines are shared with stakeholders, then the PHS communications team should also be informed in case of further enquiries from related organisations.

Additional resources

Information leaflets

Information leaflets are available for individuals who have been identified as contacts of MERS case and are under active or passive surveillance.

These are provided in Microsoft Word format with editable areas where you can customise as appropriate.

Download the leaflets

Guidance development method

This guidance was developed as a rapid update to existing HPS guidance and is an adaptation of the UKHSA guidance on MERS-CoV.

Recommendations made are aligned with the UKHSA guidance at the time of update, adapted for use in Scotland.  

A limited guidance development group (GDG) internal to PHS developed the guidance.

The GDG included:  

• PHS respiratory viral team 
• PHS border health and emerging infections team 
• PHS gastrointestinal and zoonoses team 
• PHS public health microbiology team 
• PHS guidance team 

The development process was led by the PHS guidance team, with input from topic experts within PHS.

The group identified areas where processes and pathways differ from the UKHSA guidance and agreed the relevant wording and processes for Scotland, engaging with their stakeholder groups where required. A rapid evidence review was conducted to answer one key question on the definition of end of infectious period, which was unclear in the original guidance.

The evidence was presented to the expert group for review and approval.

The guidance was signed off for publication by the division head of infection services, with responsibility for respiratory infections, zoonotic infections and border health. 

Limitations to the method used were that the process did not fully follow the agreed guidance development method.

Key variations were that:

• the GDG did not involve external partners
• no assessment of the external guidance or evidence base were undertaken
• consultation with external partners was not undertaken

These limitations will be addressed in a future update of this guidance. 

Abbreviations

Submit feedback on this guidance

Health protection teams (HPTs) and other stakeholders contribute to the development of this guidance through regular feedback and comments.

To leave feedback and comments please contact phs.shpn-admin@phs.scot

If HPTs have a specific query about the application or interpretation of the guidance, email phs.respiratory@phs.scot for non-urgent queries or call PHS for urgent queries.