MERS: How Should Public Health Departments Prepare?

This article was orginially posted in Emergency Management Weekly Newsletter.

June 2, 2014. Author: Justine Brown

Middle East Respiratory Syndrome (MERS) has been on the U.S. Centers for Disease Control and Prevention’s radar since it first appeared in Saudi Arabia in 2012. The World Health Organization called the MERS virus a “threat to the world,” because of the unknowns surrounding it, most notably how it spreads. But nothing made the threat more real than when the first case of MERS was confirmed in the U.S. on May 2, 2014.

MERS is a viral respiratory illness caused by a coronavirus called MERS-CoV. MERS has killed at least 175 people worldwide and sickened hundreds in the Middle East. It has spread from ill people to others through close contact, such as caring for or living with an infected person. People infected with MERS commonly experience fever, shortness of breath and coughing. About 30 percent of those infected with the virus die.

Given today’s interconnected world, communicable diseases are truly just a plane ride away. Therefore the potential for MERS-CoV to spread further and cause more cases globally and in the U.S. is significant. Now that MERS has officially reached U.S. soil, what should public health departments and emergency managers be doing to prepare?

The First U.S. Case

On April 24, 2014, a health-care worker who lives and works in Saudi Arabia traveled by plane from Riyadh, Saudi Arabia, to London and from London to Chicago. He then took a bus from Chicago to Indiana. On April 27, he began to experience respiratory symptoms, including shortness of breath, coughing and fever. He went to an emergency room in an Indiana hospital on April 28 and was admitted that day. Because of the patient’s symptoms and travel history, Indiana public health officials tested for MERS-CoV. The Indiana state public health laboratory and CDC confirmed MERS-CoV infection in the patient May 2, 2014, making him the first confirmed U.S. case of the virus. The patient was isolated in a hospital during the course of the illness and later discharged, having fully recovered. 

Public health officials contacted health-care workers, family members and travelers who had close contact with the patient, and so far no further contamination has been confirmed. 

On May 11, 2014, a second U.S. imported case of MERS was confirmed in another health-care worker who traveled from Saudi Arabia to Orlando via London, Boston and Atlanta. At press time, that patient was isolated in a hospital and doing well. The two U.S. cases are not linked. 

While MERS truly burst into the spotlight once the U.S. cases were reported, the CDC has actually been working to prepare for the arrival of the virus since it was first discovered. 

“We began working with state health departments and emergency managers to prepare in the summer of 2013, because we were pretty certain MERS would reach the U.S. one day, we just didn’t know when,” said Jason McDonald, spokesman for the CDC. 

In July 2013, the CDC posted checklists and resource lists for health-care facilities and providers to assist in preparing to implement infection control precautions for MERS-CoV. McDonald said the CDC also developed guidance and tools for health departments to conduct public health investigations, and provided recommendations for health-care infection control and other measures to prevent disease spread. The CDC also developed a test to detect the virus, and in August 2013 that test was distributed to all U.S. state and local health departments. Finally, the agency provided guidance for flight crews, Emergency Medical Service units at airports, and U.S. Customs and Border Protection officers about reporting ill travelers to CDC.

“The discovery of the first case in Indiana was really a heads-up move by the hospital,” McDonald said. “They called for the testing, and we were alerted that they had a positive for MERS that fit the case definition on May 1.”

Samples were then sent overnight to the CDC, and the infection was confirmed on May 2. 

“That started a chain of events,” McDonald said. “We had a team of scientists on the way there immediately. When you are dealing with infectious diseases you need to understand what the patient had been doing and the places where people could have been exposed. It was quite an effort to contact bus riders and plane riders who may have been exposed — 53 in all — and tell them what to look for and what to do.”

Case in Point

The Indiana State Department of Public Health has been praised for its swift action in the case. 

“In some respects it was similar to the H1N1 pandemic we experienced a few years back, where you have a new agent and you are trying to learn about it at the same time you’re trying to control it,” said Amy Reel, public affairs director for the Indiana State Department of Public Health. “This was the first case identified in the U.S., so it was very visible. There was a lot of media attention and a lot of communication with federal agencies. Some of the recommendations were actually being developed during the outbreak.”

For Indiana, good preparation enabled fast response. 

“The preparedness infrastructure that we’ve built since about 2003 with federal funding support was instrumental in allowing us to respond quickly to this outbreak,” said Pam Pontones, Indiana state epidemiologist. “Without that type of support and infrastructure in place this would have been much more difficult.”

Indiana State Health Commissioner William C. VanNess II said the response was really a plan that came together. “We were really pleased with the preparation that occurred and how everybody jumped in, did their job, and did it well. A lot of accolades go to the hospital, which was able to identify this fairly early, and to find the employees that had been in contact with the patient. “

VanNess said the state soon plans to review the sequence of events to see what can be learned from it and where to improve.

Pontones said much of the reaction was a result of relationships that had been built up and good communication. “Relationships with local health departments were key in helping to monitor the household contacts of the individual. The hospital staff was very responsive to monitoring the patient, locating others that may have been exposed and instituting the appropriate control measures.”

VanNess said the Indiana Department of Public Health also involved the U.S. Department of Homeland Security, because the federal agency didn’t not know which first responders might need to be involved should it face a full outbreak. Indiana also coordinated with the DHS on a message that went out to first responders advising them what to do if they received a call about the outbreak. The Department of Public Health also set up its own call center so residents with questions could call in 24 hours a day during the critical period after the case was confirmed. 

Looking back on the experience, Reel recommends states faced with a similar situation build and rely on key partnerships.

“Build those relationships with your local health department, hospitals and emergency management teams both within and outside your agency,” she said. “Build those now before you have a situation because once the situation happens, you need to be able to rely on those partnerships and relationships to get things done.”

Reel also suggested that states not be afraid to reach out and ask for help. “We want to learn from other states and likewise, Florida consulted with us when they confirmed a case of MERS,” she said. “These things don’t stop at the state lines. Often federal agencies and other state agencies will be required to help, so having clear early communication and asking for help or resources when they are needed is key.”

Vigilance Is Critical

In Florida, collaboration and partnerships were equally critical when the second U.S. case of MERS was confirmed there on May 11. The Florida Department of Health worked hand in hand with local and state partners, including Orange County and Orlando, emergency management officials, hospitals, the travel industry and others to provide an effective response. The department established its response to the situation based on the Incident Command System (ICS). 

Ann Rowe, lead crisis and risk communications coordinator for the Florida Department of Health, said that by establishing a response based on the ICS, health professionals, responders and partners were able to benefit from the use of its changeable, scalable structure in order to successfully coordinate a wide range of efforts. She said this ensured that those responders trained under the umbrellas of planning, operations, logistics, finance/administration, safety, public information and other sections from necessary agencies and organizations were included. 

Rowe said the Florida Department of Health and response partners train on the ICS throughout the year. As the MERS case in Florida was discovered, the state’s Department of Health and partners were able to effectively respond by designating an incident commander who served as lead for the response. The commander collaborated with state and federal health professionals to safely transport samples and conduct lab testing; set up a call center to answer questions from the community; shared information among partners via the use of a Virtual Joint Information Center; and held press conferences to provide coordinated health-related messaging to the public. 

Like in Indiana, Rowe said being prepared and knowing its partners were key to the state’s success. “Get to know your public health partners at the local and state level,” Rowe said. She also suggested learning about the public health issues they handle on a daily and emergency basis and to become familiar with their response processes and procedures, and to share information and best practices. “Practice consistently with partner organizations and engage them during ‘blue skies’ in various trainings and exercise scenarios so the response will be as effective as possible.”

At press time, no other cases of MERS had been reported in the U.S. (a second reported case in Indiana turned out to be a false positive). However, the CDC continues to closely monitor the MERS situation globally and work with partners to better understand the risks of the virus, including the source, how it spreads and how infections might be prevented. McDonald said that overall the MERS situation in the U.S. represents a very low risk to the general public. Yet the CDC recognizes the potential for MERS-CoV to spread further and cause more cases globally. 

In the meantime, McDonald recommends that state emergency managers and health department remain vigilant, be prepared to help with investigations and respond quickly to any signs of MERS in their respective states.  


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