APPLICATION OF COMMUNITY HEALTH & POPULATION-FOCUSED NURSING
VWT Task 2
Middle Eastern Respiratory Syndrome (MERS)
Kelly Belcher 307442
Western Governors University
("INSTITUTO DE BIOLOGIA & INGENIERIA DE ECOSISTEMAS: RUSSIAN REPORT WARNS OF GRAVE MONSANTO THREAT TO WORLD," n.d.)

I chose to do this assignment about the Middle East Respiratory Syndrome (MERS). It is caused by the coronavirus MERS-CoV. I have never heard of this condition, and arbitrarily picked it because my best friend’s last name is Corona. I was interested to learn that, ironically, the only known case in the US was in Indiana, where I live. “Coronaviruses are common viruses that most people get some time in their life. Human coronaviruses usually cause mild to moderate upper-respiratory tract illnesses” ("CDC - Coronavirus - About," n.d.), but >30% of people who have MERS will die from it ("CDC - Coronavirus - Middle East Respiratory Syndrome - MERS-CoV," n.d.). MERS was originally diagnosed in Saudi Arabia in 2012. It is a virus that attacks the respiratory tract. Typically the people who test positive for the virus show the same symptoms. They have a fever, cough, and shortness of breath and may also have pneumonia, sore throat, nausea, vomiting, and diarrhea. To discuss the epidemiological determinants of this disease I first needed to establish a working definition. “A determinant is any factor or variable that can affect the frequency with which a disease occurs in a population” ("2. Epidemiology: some basic concepts and definitions," n.d.). MERS is a disease that has been localized to Saudi Arabia and the surrounding countries but “Every year, more than 1 million pilgrims from African countries travel to Makkah and Madinah, Kingdom of Saudi Arabia (KSA) to join 10 million other pilgrims from around the globe” ("The Hajj pilgrimage and surveillance for Middle East Respiratory syndrome coronavirus in pilgrims from African countries - Zumla - 2014 - Tropical Medicine & International Health - Wiley Online Library," n.d.). With so many people staying in close proximity to one another while coming and going from the area where the disease originated, there is a huge potential for the virus to be spread into the rest of the continent and the world. These pilgrims also have the potential of coming into direct contact with the camels and bats that are known to carry the virus, or the local population who raise the camels and will provide them goods and services. After much research I have not been able to narrow down the exact route of transmission of this disease ie respiratory droplets or direct contact. The World Health Organization (WHO) and Center for Disease Control (CDC) both have extensive data posted on their websites but the knowledge of route of transmission is described as most likely originating in animals and transferring to humans. Concerning human to human contact “MERS-CoV has spread from ill people to others through close contact, such as caring for or living with an infected person” ("CDC-MERS-About Transmission," n.d.) and there is a documented case in France of a patient contracting it from sharing a hospital room with an infected patient. This suggests that contact and respiratory droplet transmission are both probable routes of transmission. Risk factors for the majority of the world’s population acquiring MERS are minimal. Location is a large risk factor, since the disease is primarily seen in those who live in the Arabian Peninsula, travel there, or come into contact with others who do. Travelers to the area whether for work, leisure or religious reasons increase their risk of being exposed to the virus. People with other health co-morbidities have increased risk from dying of the disease. Those who live and work with the Qatar camel (known carriers of the virus) are at increased risk as well. Despite direct links with the area, there is still the question of whether people with Middle Eastern genetics are more susceptible to the disease. Also it could be argued that because the research focus is localized in studying sick persons associated with this area, that other outbreaks may not be easily identified. Despite the limited risk factors, cases of MERS have been reported in UK, France, Germany, Italy and the US. Each of these was either a traveler to KSA or someone who had direct contact with one. The disease does not seem to be particularly proliferate and once identified placing patients in contact and respiratory isolation stops the transmission of the virus. There is no cure or vaccine for MERS, and supportive therapy is the course of treatment. That being the case, detection is of utmost importance. Screening of anyone who displays the symptoms attributed to the virus is vital. In the St Francis, Indianapolis ER, all patients are asked a standard “have you had any recent travel outside the country or known exposure to communicable diseases” question and very rarely is there a “yes” answer that would prompt further investigation to find out exact details and exposure timelines. There is a process in place where the patient known to have a potential exposure risk is placed in isolation and the infectious disease officer contacted. The drawback being that by the time the screening is complete, the infected patient has been through triage, and down the hall to a room, and has possibly coughed on at least 2 nurses, a registration clerk, and a physician or physicians assistant, along with any other patients and visitors who were in their pathway. If the patient was brought in by ambulance, that crew was exposed as well. There are masks available at the triage desk but they are not always utilized. Once there is a need for the infectious disease officer to become involved, Indiana has an algorithm concerning reporting illness ("Laboratory Testing Algorithm for Patients with Suspect MERS-CoV," n.d.) and local hospitals, airlines, and new media are put on alert for suspicious symptom presentation.

According to the CDC once someone is diagnosed with with MERS, if they do not require hospitalization, they may be quarantined at home. The quarantine is initiated by the diagnosing physician and coordinated with the CDC and the local health officer. In the case of home quarantine, it is recommended that others who live in the home stay somewhere else. When that is not possible, it is recommended that those who test positive stay in separate rooms and do not share eating utensils, or restrooms. The individual and possibly their close associates must be isolated from job, friends, and family. They become dependent on others to provide their care, run their errands, and basically they become prisoners in their own home. Even if the person survives, they are sick long enough to likely lose their job and by association the health insurance to pay for treatments. This can escalate into not being able to pay bills and possibly losing their possessions. The havoc that this could wreak on a person, family or community could lead to secondary issues like depression, poor self esteem and decreased resources. Considering how much contact people make with others these days, these effects could quickly snowball through a community. This could lead to a drain on resources at the local and state level. Symptoms from MERS can occur 2-14 days post exposure, so theoretically someone can pass the virus on before they are aware they have contracted it. This being the case, education about where and how it is contracted, along with how it is spread are keys to controlling MERS-CoV. Passing out ‘Quick Fact’ brochures, in multiple languages, with tickets purchased for travel to KSA and providing masks would be two ways to educate and equip the traveling public at risk. Travelers and health care workers should be educated on being vigilant to wear masks and wash hands to protect themselves and keep track of any ill persons they come into contact with. According to the WHO there is small chance of airplane travelers getting it on a flight “Research has shown that there is very little risk of any communicable disease being transmitted on board an aircraft” ("WHO | World Health Organization," n.d.). Despite this airlines should still screen for suspected sick people and not allow them to fly. The continued alliance of the WHO, and CDC working with local authorities in the outbreak areas is vital to track and educate about this disease.

Men wearing surgical masks as a precautionary measure against the Middle East Respiratory Syndrome coronavirus (MERS-CoV), speak at a hospital in Khobar city in Saudi Arabia (file photo). ("PressTV - WHO announces 2 new cases of MERS in Saudi Arabia," n.d.)

References
2. Epidemiology: some basic concepts and definitions. (n.d.). Retrieved from http://www.fao.org/wairdocs/ilri/x5436e/x5436e04.htm
CDC - Coronavirus - About. (n.d.). Retrieved from http://www.cdc.gov/coronavirus/about/index.html
CDC - Coronavirus - Middle East Respiratory Syndrome - MERS-CoV. (n.d.). Retrieved from http://www.cdc.gov/coronavirus/mers/
CDC - Infectious Diseases - Adolescent and School Health. (n.d.). Retrieved from http://www.cdc.gov/healthyyouth/infectious/
CDC-MERS-About Transmission. (n.d.). Retrieved from http://www.cdc.gov/coronavirus/MERS/about/transmission.html
The Hajj pilgrimage and surveillance for Middle East Respiratory syndrome coronavirus in pilgrims from African countries - Zumla - 2014 - Tropical Medicine & International Health - Wiley Online Library. (n.d.). Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/tmi.12318/full
INSTITUTO DE BIOLOGIA & INGENIERIA DE ECOSISTEMAS: RUSSIAN REPORT WARNS OF GRAVE MONSANTO THREAT TO WORLD. (n.d.). Retrieved from http://instbioingecosist.blogspot.com/2013/06/russian-report-warns-of-grave-monsanto.html
ISDH: ISDH Home. (n.d.). Retrieved from http://www.in.gov/isdh/
ISDH: Novel Coronavirus renamed MERS Coronavirus. (n.d.). Retrieved from http://www.in.gov/isdh/25796.htm
Laboratory Testing Algorithm for Patients with Suspect MERS-CoV. (n.d.). Retrieved from http://www.state.in.us/isdh/files/MERSCoV_Flow_Chart(3).pdf
PressTV - WHO announces 2 new cases of MERS in Saudi Arabia. (n.d.). Retrieved from http://www.presstv.ir/detail/2013/12/18/340668/who-announces-new-cases-of-mers-in-ksa/
Report incidences of the following infections, diseases, or conditions to the Local Health Department. (2008, December 12). Retrieved from http://www.state.in.us/isdh/files/ReportableDiseaseList.pdf
Summary and Key Points – Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (Formally called Novel Coronavirus, or nCoV). (n.d.). Retrieved from http://www.in.gov/isdh/files/Novel_coronavirus_update_5_29_13.pdf
WHO | Middle East respiratory syndrome coronavirus (MERS-CoV) – update. (n.d.). Retrieved from http://www.who.int/csr/don/2014_07_14_mers/en/
WHO | World Health Organization. (n.d.). Retrieved from http://www.who.int/ith/mode_of_travel/tcd_aircraft/en/