CDC Health Update
The Centers for Disease Control and Prevention (CDC) is working closely with the World Health Organization (WHO) and other partners to better understand the public health risk posed by Middle East Respiratory Syndrome Coronavirus (MERS-CoV), a novel coronavirus that was first reported to cause human infection in September 2012. No cases have been reported in the United States. The purpose of this HAN Advisory is to provide updated guidance to state health departments and health care providers in the evaluation of patients for MERS-CoV infection including expansion of availability of laboratory testing and, in consultation with WHO, expansion of the travel history criteria for patients under investigation from within 10 to 14 days for investigation and modification of the case definition. Please disseminate this information to infectious diseases specialists, intensive care physicians, internists, infection preventionists, as well as to emergency departments and microbiology laboratories.
Background: MERS-CoV, formerly called “novel coronavirus,” is a beta coronavirus that was first described in September 2012, when it was reported to have caused fatal acute lower respiratory illness in a man in Saudi Arabia. Genetic sequence analyses have shown that this new virus is different from other known human coronaviruses, including the one that caused severe acute respiratory syndrome (SARS). Diagnosis relies on testing with real time reverse transcription polymerase chain reaction (RT-PCR) assays. There is no specific treatment for MERS-CoV infection; care is supportive.
As of June 7, 2013, 55 laboratory-confirmed cases of MERS-CoV infection have been reported to WHO—two from France, three from Italy, two from Jordan, two from Qatar, 40 from Saudi Arabia, two from Tunisia, one from the United Arab Emirates, and three from the United Kingdom (UK). Additional details can be found in the June 7, 2013 MMWR Early Release (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm62e0607a1.htm?s_cid=mm62e0607a1_w). To date, all cases have a direct or indirect link to one of four countries: Saudi Arabia, Qatar, Jordan, and the United Arab Emirates. No cases have been reported in the United States. Illness onsets were from April 2012 through May 2013. Of the 55 cases, 31 were fatal, for a case-fatality rate of 56%. The median age of cases is 56 years. All of the patients were aged >24 years, except for two children, one aged 2 years and one aged 14 years.
Eight clusters of illnesses have been reported by six countries (France, Italy, Jordan, Saudi Arabia, Tunisia, and UK). These clusters provide clear evidence of human-to-human transmission of MERS-CoV. The largest cluster reported to date consists of 25 cases, 14 of which were fatal, associated with a health-care facility in Al-Ahsa governorate in Saudi Arabia. Two of the case-patients in that cluster were health-care personnel who acquired the infection after exposure to patients with confirmed MERS-CoV infection.
The first case reported by France was in a person with an underlying immunosuppressive condition who initially had abdominal pain and diarrhea and subsequently developed respiratory complications. This case raises the possibility that presentations may not initially include respiratory symptoms. Among cases reported to WHO in which more detailed information is available, most are reported to have chronic underlying medical conditions or immunosuppression; such persons may be at increased risk of MERS-CoV infection or severe disease, or both. In some instances, sampling with nasopharyngeal swabs did not detect MERS-CoV by PCR; however, MERS-CoV was detected by PCR in lower respiratory tract specimens from those same patients. Therefore, lower tract respiratory specimens should be a priority for collection and PCR testing, in addition to nasopharyngeal swabs.
Recommendations: Recommendations and guidance on MERS-CoV case definitions, case investigation, specimen collection and shipment for testing, and infection control (including use of personal protective equipment) are available at the CDC MERS website (http://www.cdc.gov/coronavirus/MERS/index.html). Information and guidance posted on this website may change as we learn more about the virus. Please check CDC’s MERS website regularly for the most current information. State and local health departments with questions should contact the CDC Emergency Operations Center (770-488-7100 or eocreport@cdc.gov).
Surveillance
As a result of investigations suggesting incubation periods for MERS CoV may be longer than 10 days, the time period for considering MERS in persons who develop severe acute lower respiratory illness days after traveling from the Arabian Peninsula or neighboring countries* has been extended from within 10 days to within 14 days of travel.
In particular, persons who meet the following criteria for “patient under investigation” (PUI) should be reported to state and local health departments and evaluated for MERS-CoV infection:
- A person with an acute respiratory infection, which may include fever (≥ 38°C , 100.4°F) and cough; AND
- Suspicion of pulmonary parenchymal disease (e.g., pneumonia or acute respiratory distress syndrome based on clinical or radiological evidence of consolidation); AND
- History of travel from the Arabian Peninsula or neighboring countries* within 14 days; AND
- Symptoms not already explained by any other infection or etiology, including clinically indicated tests for community-acquired pneumonia† according to local management guidelines.
In addition, the following persons may be considered for evaluation for MERS-CoV infection:
- Persons who develop severe acute lower respiratory illness of known etiology within 14 days after traveling from the Arabian Peninsula or neighboring countries* but who do not respond to appropriate therapy; OR
- Persons who develop severe acute lower respiratory illness who are close contacts‡ of a symptomatic traveler who developed fever and acute respiratory illness within 14 days of traveling from the Arabian Peninsula or neighboring countries.*
In addition, CDC recommends that clusters of severe acute respiratory illness (SARI) should be investigated and, if no obvious etiology is identified, local public health officials should be notified and testing for MERS-CoV conducted if indicated.
CDC requests that state and local health departments report PUIs for MERS-CoV and clusters of SARI with no identified etiology to CDC. To collect data on PUIs, please use CDC’s Interim Health Departments MERS-CoV Investigation Form available at http://www.cdc.gov/coronavirus/mers/guidance.html. State health departments should FAX completed investigation forms to CDC at 770-488-7107 or attach in an email to eocreport@cdc.gov (subject line: MERS-CoV Patient Form).
Laboratory Testing
Testing of specimens for MERS-CoV is currently being conducted at CDC. The Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) on June 5, 2013, to authorize the use of the CDC Novel Coronavirus 2012 Real-time RT-PCR Assay (NCV-2-12 rRT-PCR Assay) to test for MERS-CoV in clinical respiratory, blood and stool samples. This EUA is needed because, at this time, no FDA-approved tests that identify MERS-CoV in clinical specimens are available. This assay will be deployed to Laboratory Response Network (LRN) laboratories in all 50 states over the coming weeks. Updated information about laboratories with the capacity to conduct MERS testing with the NCV-2-12 rRT-PCR Assay will be provided on CDC’s MERS website (http://www.cdc.gov/coronavirus/mers/case-def.html).
To increase the likelihood of detecting MERS-CoV, CDC recommends collection of specimens from different sites– for example, a nasopharyngeal swab and a lower respiratory tract specimen such as sputum, bronchoalveolar lavage, bronchial wash, or tracheal aspirate. Specimens should be collected at different times after symptom onset, if possible. Lower respiratory tract specimens should be a priority for collection and PCR testing; stool specimens are of lower priority. Specimens should be collected with appropriate infection control precautions http://www.cdc.gov/coronavirus/mers/case-def.html.
Case Definitions
The MERS-CoV case definition continues to evolve and is available at http://www.cdc.gov/coronavirus/mers/case-def.html. In consultation with WHO, the definition of a probable case of MERS has been updated to also include persons with severe acute respiratory infection with no known etiology with an epidemiologic link to a confirmed MERS-CoV case.
Infection Control
There is clear evidence of limited human-to-human transmission, possibly involving different modes, such as droplet and contact transmission, but further studies are required to better understand the risks. Until the transmission characteristics of MERS-CoV are better understood, patients under investigation and probable and confirmed cases should be managed in healthcare facilities using standard, contact, and airborne precautions. As information becomes available, these recommendations will be re-evaluated and updated as needed.
* Countries considered to be on or neighboring the Arabian Peninsula include Bahrain, Iraq, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Palestinian territories, Qatar, Saudi Arabia, Syria, the United Arab Emirates (UAE), and Yemen.
† Examples of respiratory pathogens causing community-acquired pneumonia include influenza A and B, respiratory syncytial virus, adenovirus, Streptococcus pneumoniae, and Legionella pneumophila.
‡ Close contact is defined as 1) any person who provided care for the patient, including a health-care worker or family member, or who had other similarly close physical contact, or 2) any person who stayed at the same place (e.g., lived with or visited) as the patient while the patient was ill.
For more information: please consult the CDC MERS website at: http://www.cdc.gov/coronavirus/mers/index.html
State and local health departments with questions should contact the CDC Emergency Operations Center (770-488-7100 or eocreport@cdc.gov).
The Centers for Disease Control and Prevention (CDC) protects people’s health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations.
MNA NewsScan, June 10, 2013: Long-term damage to health research from budget cuts
NOTES ON NURSING
AHRQ Seeks Comments From Patients to Help Develop Patient Safety Reporting System There is a growing body of evidence that many adverse medical events go unreported in current systems. One important reason for this reporting gap is that most reporting systems do not presently accept or elicit reports from patients and their families. AHRQ recognizes that the unique perspective of health care consumers could reveal important information that is not reported by health care providers. NOTE: Comment deadline is July 8, 2013
On the Wings of a Nightingale Today I ran into a Mexican restaurant to grab a quick lunch, and as I ate my meal I came across a table of nurses wearing hospital scrubs. As they chatted amongst themselves I thought about the many nurses my family has interacted with over the last five years, and I found myself filled with such appreciation for what these amazing women and men do for us.
HEALTH CARE
Is Self-Rationing of Medications a Good or a Bad Thing? In America, the conventional wisdom is that we don’t ration health care. But we do, and there’s no better example than patients rationing themselves when it comes to the medicines they take.
Research Forgotten by Budget Cuts The N.I.H. funding is cut 5 percent, or $1.55 billion this year, across the board. That means 700 fewer research grants are approved and 750 fewer patients will be admitted to its clinical center. The longer the automatic cuts go on, the worse it will get; medical breakthroughs are rarely instant. They take years and build on previous studies and experiments.
LABOR UPDATES
Union Membership Decline Boosts Corporate Profit at Workers’ Expense “It’s a zero sum game: whatever is not going to workers, goes to corporations,” Kristal said. “Union decline not only increased wage gaps among workers, but also enabled capitalists to grab a larger slice of the national income pie at the expense of all workers, including the highly skilled.”
DPH Issues Finding Declaring Pediatric Unit at Steward Morton Hospital an Essential Service
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MNA Legislative Recap
The 2013 legislative session ended last week with some significant improvements and changes to policies that affect nursing, health care and working families. In addition, with the change in legislative majorities to DFL control of the House and Senate, we did not have to fight off threats like Right to Work legislation, deep cuts to programs, or the Interstate Nurse Licensure Compact.
Safe Staffing
We made major progress toward our goal of minimum standards for nursing care in acute care hospitals. Our bill for a Department of Health study of the correlation between nurse staffing and patient health outcomes was signed into law by Governor Dayton. We are confident this study will validate what nurses have been saying for years: patients suffer when staffing is inadequate.
The bill will also require hospitals to report their staffing levels on a public website, which will provide transparency for the public.
Nurse Practice Act Changes
Governor Dayton signed into law a bill clarifying the scope of practice of Licensed Practical Nurses. The measure goes into effect on August 1. SF1016 was crafted after years of discussions between MNA, the Licensed Practical Nurse Alliance and the Board of Nursing. The final product clarifies and strengthens the Nurse Practice Act for both LPNs and RNs. Specifically, the law clarifies the definitions of assignment, delegation and unlicensed assistive personnel.
The Board of Nursing has committed to conducting education sessions for nurses on this issue. We will alert you when those opportunities are scheduled.
State Employee Contract
Last session the contract for over 700 MNA nurses in state facilities, agreed to by both management and employees, was voted down by the Republican-controlled legislature after continued attacks on public employees. During this legislative session the same contract was approved by the House and Senate and signed into law by Governor Dayton. Nurses at state facilities will see a 2 percent raise retroactive to this year.
Budget and Taxes
Minnesota now has a budget that invests in our future and protects the health of seniors and working families, while making the tax system fairer.
The top 2 percent of wage earners will pay about 2 percent more in taxes, which will raise $1 billion dollars; cigarette and other tobacco taxes will go up, which will raise another $600 million and hopefully convince some to quit; and the state will close corporate tax loopholes, which will raise $424 million.
Doing all that meant the Governor could sign an $11.2 billion health and human services budget bill, which includes a 5 percent rate increase for nursing homes next year-of which over half will go to workers who care for our seniors-along with another 3.2 percent increase by 2016.
MNCare will continue to provide high-quality affordable health care for working families in 2014 and beyond, making Minnesota the ONLY state that is continuing a public health coverage program in 2014 that will be able to transition to the Basic Health Plan option under the Affordable Care Act (ACA) in 2015. Basic Health Plan financing offered through the ACA means our state budget will see significant savings starting in 2015.
Patients will benefit from improvements to MNCare including elimination of the $10,000 hospital cap, lower premiums and elimination of the waiting period to get on the program. Expansion of Medicaid will add health care coverage for 35,000 low-income people.
You are invited: Legislative Wrap-Up Briefing
Come learn more about the legislative session, including more in-depth information about the staffing study, at the MNA Legislative Wrap-Up Briefing.
WHEN: Tuesday, June 11, 4:00 – 5:30 pm
WHERE: At the MNA office in St. Paul, 345 Randolph Avenue, Suite 200, St. Paul 55102 or via webcast
This event is for MNA members only and requires an RSVP. Please contact Eileen Gavin at eileen.gavin@mnnurses.org and let her know if you plan to participate in person or online. (Online participants will need an RSVP code to join the event.)
MNA NewsScan, June 5, 2013: RN college degree equals lowest unemployment rate
NOTES ON NURSING
Night Shift Workers More Likely to Develop Type 2 Diabetes ”It is surprising that just a single night shift can significantly impair glucose tolerance and increase insulin levels,” said Christopher Morris.
National Health System May Bring In Police Officers to Deal with Acute Nursing Shortage A local forum has discussed the possibility of drafting in assistance from Police Scotland and the Red Cross. Two months ago it was announced that 30 nursing posts had to be filled as soon as possible at the hospital.
New Law Raises Fines for Assaulting Nurses Much like law enforcement, health care can be a very dangerous job. The Bureau of Labor Statistics reports more than 2,000 nurses nationwide were assaulted, and eight were killed while on the job between 2003 and 2009.
LABOR UPDATES
Not All College Degrees are Created Equal For instance, the unemployment rate for recent college graduates in nursing was the lowest at 4.8 percent, while recent graduates in information systems, concentrated in clerical functions, were the hardest hit with an unemployment rate of 14.7 percent.
