The EMS Role in Stopping MERS-CoV

The newest emerging infectious disease to capture the attention of healthcare providers, public health professionals and policymakers is the Middle East Respiratory Syndrome coronavirus (MERS-CoV). This virus emerged last year, and as of July 7 the World Health Organization had tallied 80 confirmed infections since September 2012, with 44 deaths to date.

While there has not yet been a confirmed case of MERS diagnosed in the United States, the virus spreads with close human contact and is just an airplane ride away. Consequently, the rapid identification of imported MERS cases is critical from patient care, epidemic prevention and provider safety standpoints. As EMS is a common portal into the healthcare system for the acutely ill, paramedics and EMTs who incorporate travel histories into their patient assessments can contribute to the health and safety of their colleagues and communities by shortening the reporting and response timeline.

Broadly speaking, communicable diseases are detected in one of two ways. Public health agencies use a wide array of surveillance systems for specific diseases or syndromes. Alternatively, upon patient contact, a treating physician will develop a hypothesis (called a working diagnosis) concerning the nature of the causative pathogen, which is then confirmed by laboratory testing. When the diagnosis proves correct and pathogen is rare, novel or particularly dangerous, this type of doctor is often described in the literature as an “astute clinician.” Because there is often a time lag associated with public health reporting, the “astute clinician” is often the most sensitive and timely disease detector available.

One of the reasons why this particular pathogen is significant, and its detection critical, is that it is closely related to the SARS coronavirus. We know from the epidemiology of that outbreak in Canada that hospitals acted as disease amplifiers, and that healthcare providers there were at increased risk of infection. Health Canada concluded in its 2003 report Learning From SARS: Renewal of Public Health in Canada, “The high rates of transmission to healthcare workers during SARS indicated that many had ‘limited awareness of the correct precautions and/or how to apply them.’”¹

We also know from our experience with SARS that proper and prompt infection control measures can help limit the spread of communicable disease. From what is known about MERS-CoV thus far, it appears to behave in a similar fashion.² But in order for such controls to be implemented, the disease must first be suspected.

This is where EMS comes in. It is not out of the realm of possibility that an arriving or returning traveler from the Middle East³—or a traveler’s close contact—develops a severe respiratory illness (+/- fever, GI symptoms) and calls for an ambulance. While disease diagnosis is out of the EMS scope of practice, patient assessment is not. In order to act as detectors for possible MERS infections, paramedics and EMTs should:

1. Become familiar with the CDC case definition for MERS patients (see www.cdc.gov/coronavirus/mers/index.html).

2. For patients who fit the CDC’s criteria, prioritize the collection of travel history and the travel histories of contacts to countries in the Middle East.

If both findings are present, EMS providers should emphasize those points to the receiving facility during their report. The voicing of such reasonable suspicion could potentially lead to more rapid diagnostic testing, implementation of protective measures and ultimately lives saved. In this way, paramedics and EMTs can also assume the role of the “astute clinician.”

References

1. Naylor D, Basrur S, Bergeron MG, et al; National Advisory Committee on SARS and Public Health. Learning from SARS: Renewal of Public Health in Canada,www.phac-aspc.gc.ca/publicat/sars-sras/pdf/sars-e.pdf.

2. Assiri A, McGeer A, Perl TM, et al; the KSA MERS-CoV Investigation Team. Hospital Outbreak of Middle East Respiratory Syndrome Coronavirus. N Engl J Med, 2013 Jun 19 [e-pub ahead of print].

3. The CDC lists Bahrain, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, the Palestinian territories, Qatar, Saudi Arabia, Syria, the United Arab Emirates and Yemen as countries of interest.

Matthew Watson is a senior analyst at the University of Pittsburgh Medical Center’s Center for Health Security.