MERS Outbreak in the Republic of Korea

Lablogatory spoke to Kyung Jin Cho, PhD, from the Department of Health and Environmental Science at Korea University about the current outbreak of MERS in the Republic of Korea. This is what he had to say.

Lablogatory: What can you tell us about MERS in the Republic of Korea?

Dr. Cho: MERS is a viral respiratory infection caused by Middle East Respiratory Syndrome Coronavirus (MERS-CoV). The MERS-CoV belongs to the coronavirus family (beta coronavirus). Many MERS patients developed severe acute respiratory illness with symptoms of fever, cough, expectoration, and shortness of breath. The cause of MERS is not yet fully understood. Some infected people had mild symptoms or recovered. Incubation period is known as 2-14 days. The incubation periods are still under dispute since a few cases in Korea reported incubation periods longer than 14 days. Fortunately, the MERS outbreak appears to be subsiding with one or two new cases are reported daily. Many people under the house quarantine at the peak of MERS outbreak are now released.

The Korean MERS portal reported that there are 27 deaths from 175 cases as of June 23, since the first MERS patient was confirmed on May 20, 2015 (Fatality rate: 15.4%). Most of the people who died had an underlying disease such as chronic lung and kidney disease, cancer, and diabetes mellitus. Of the 27 deaths, 74.1% were male and all were over the age of 40. Of the 175 confirmed cases, male 107 (61.1%), female 68 (38.9%); the Inpatient/outpatients 80 (45.7%), family members/visitors visiting sick persons 62 (35.4%), staff and other hospital employees 33 (18.9%). Most of the MERS cases were infected within the medical facilities. The cumulative number of released individuals from quarantine is 10,718. The current number of isolated is 2,805 (home 2,091 and institution 714).

Lablogatory: How fast is it traveling within Republic of Korea?

Dr. Cho: The major second place of MERS spread was a mammoth hospital which is a top-class institution in Seoul. Within a large hospital, the Hospital S, nearly half of the cases (82 of 166 cases, As of Jun 20, 2015) were exposed to the MERS during June 5th through June 10th. The hospital S admitted the 14th case of MERS and became the epicenter of the second generation of MERS cases. The health authority failed to carry out timely control measures against MERS. The authority and the hospital S were harshly blamed for the late response in the beginning of MERS outbreak.

During the MERS outbreak, a few doubtful MERS patients roamed about a few institutions. Some local hospitals had to refer their untreated cases to the tertiary hospitals located in big cities, like Seoul or Busan, which have excellent specialists and more resources. Unfortunately, some of the hospitals could not cope with the unexpected MERS outbreak. The triage systems in some medical institutions and the house quarantines were not operated successfully at the beginning, which contributed to the spread.

Lablogatory: Beyond the basic protocols, what other measures are being put in place, or SHOULD be put in place to stop the spread of this virus?

Dr. Cho: The Government’s rapid-response team (RST) should have activated much earlier. Government should have timely announced the list of hospitals in which MERS cases appeared and should have issued the compulsory order for the closure or partial closure of the few target hospitals much earlier. We realized that there are too few officials who are working for the government as experts in the epidemiology.

Also, the number of efficient Airborne Infection Isolation Room (AIIR) is largely insufficient. The possibility of MERS spread within the patients’ rooms and emergency room might be much higher than we would have expected.

Even though the government and some hospitals didn’t make timely responses, they disclosed the list of 84 hospitals (As of June 20th, 2015) that had MERS cases onset or MERS cases passed by. They also announced the list of 251 safe hospitals so that general citizens and respiratory patients can take the treatment under the safe conditions.

Seoul City authority asked citizens of Seoul to report MERS outbreak to Dasan Call Center (120) or official website of the Seoul metropolitan city. Citizens of other areas can report the outbreak to Korea government’s official website.

Through text messages or phone calls, the Hospital S tried to reach all the people who visited the Hospital S during the periods of high MERS exposure. Most of citizens are now well complying with the government measures.

Since some MERS patients in Korea exhibited symptoms beyond the two-week latency period, local health authorities will maintain a tent at the entrance of the town for more five days with staff to monitor if any villagers show symptoms.

The health authority is monitoring three hospitals intensively ( Hospital G in Seoul, Hospital A in Chungcheong province and Hospital G in Busan) that could possibly become new epicenters for the spread of MERS.

Lablogatory: How should institutions protect laboratory workers? What steps can clinical laboratory scientists take to protect themselves?

Dr. Cho: Information can be found here:“The Guidelines on Diagnostic Testing for MERS.” These guidelines include information about specimen collection, transport, and testing.


Sample Collection

When laboratory scientists collect samples during the aerosol-generating procedures such as sputum examination, bronchoscopy, positive pressure breathing, tracheal aspiration, and intubation/extubation, the lab scientist should follow the Infection Control Guidelines in Specimen Collection when performing Aerosol-generating Procedures. Even when lab scientists collect non-respiratory samples such as blood, they should wear the N95 mask.

  1. The procedures should be done by minimal number of health personnel within Airborne
    Infection Isolation Room (AIIR) or single patient room
  2. Health personnel protection
    1) PPE: N95 mask or higher grade equipment for respiratory protection, gloves, gown
    with long sleeves, goggle and face shield
    2) Minimize entry and exit of the isolation room during the aerosol generating procedures
    3) Maintain 6-12 times of ventilation per hour
    4) Keep the hand hygiene practices before and after the patient contact and after the
    doffing of PPE
    5) Clean the isolation room after using and keep the room empty for 30 minute after room
    cleaning in case of 12 times ventilation per hour

Transport of Infectious Substances

  1. Packaging and Transporting Within Healthcare Institutions
    1) After placing the specimens in the primary receptacle, the outer surface of the receptacle is disinfected with 70% alcohol swab, then put the primary receptacle into a zipper bag and packed in the second receptacle and transported to the destination.
  2. External Transport
    1) Specimen is placed into the primary receptacle and wrapped with parafilm, then
    disinfected with 70% alcohol swab.
    2) A zipper bag containing the primary receptacle with some absorbent is placed into the second receptacle and prop them up not to fall, and put on a lid tightly.
    3) Place second receptacle along with specimen data, letters and test request form into the third receptacle in the form of a triple packaging.

Specimen Processing and Perform Test

  1. Lab scientist should wear adequate PPEs and handle the specimen within the biological safety cabinet (BSC) class II.
  2. For the testing, lab scientist should follow the technical manual of the respective reagents that are used in each institution.
  3. In order to prevent the cross-contamination, lab scientist should extract nucleic acid from the specimen one sample at a time after pretreatment.
  4. Automated nucleic acid extraction equipment recommended by WHO can be used: Lab scientist should wear PPEs of Level D. After dispensing within a BSC class II, the specimens are loaded on the extraction equipment.
  5. Lab scientist should comply with the Regulations for laboratory biological safety that includes the disinfection of BSC work surface after specimens are processed.

Laboratory Biological Safety

  1. Use of PPE
    1) Wear the PPE of Level D: Whenever the specimens are handled, lab scientist should wear disposable globes and laboratory gown. If there are possibilities of splash during the opening of receptacles, the lab scientist should wear a dental mask and a goggle. At the completion of laboratory testing, doff the PPE and wash hands prior to leaving the testing area.
    * For the prevention of contamination of hands or body from the used PPE, the lab
    scientist should be careful while he or she doffs the PPE.
    * When there is a high risk of aerosol-generating processing, lab scientist should wear an N95 mask.
    2) Processes that require Class II Biological Safety Cabinet (BSC).
    Hand wash after doffing of gloves at the completion of BSC work. Laboratory coat
    should preferably be long-sleeved and open at the back. Use disposable gloves.
    3) The safeguard action system of equipment should be applied (Dual-lid centrifuge:
    installation and detachment of buckets or rotors for specimens should be done within the BSC).
    4) Minimize the possibility of unwanted contact with the specimen outside the BSC.
    5) At the completion of specimen handling, the work surface of BSC should be disinfected with 70% ethanol.
    6) The supplies that contact infectious specimen should preferably be disposable ones. In the event of contamination, they should be autoclaved before disposal.
  1. Handling of specimen for routine test (Biochemistry, hematology and other tests)
    1)When performing hematology and chemistry test with blood, serum and urine specimen, the standard precaution should be applied like any other routine clinical specimen.
    2) Manual cell counts and cytospin of bronchoalveolar lavage (BAL) should be done with the BSC.
    3)The routine tests that should be done following lab safety regulations at BSL-2
    (1) Histo-pathological examination of tissues that are fixed with formalin or other ways
    (2) Molecular biological test using nucleic acid extract.
    (3) Electron microscopic examination after fixation with glutaraldehyde.
    (4) Culture test of bacteria and fungus at the microbiology laboratory.
    (5) In the triple packaging of infectious specimen: the specimen contained in the
    secondary receptacle can be tested at the BSL-2.
    (6) Inactivated specimen (the specimen contained in the nucleic acid extract).
    4) The procedures that have to use Class II BSC
    (1) Dispense and dilution of infectious specimen.
    (2) Inoculation on medium for the culture of bacteria and fungus.
    (3) Diagnostic test for infectious specimen excepting the proliferation of virus.
    (4) Extraction of nucleic acids from infectious specimen.
    (5) The transportation of specimen outside BSC after extinction of bacteria   through chemical or heat fixation for the preparation of smear for microscopic exam.

Source: The web sites of MERS portal prepared by the Ministry of Health and Welfare and Korea Center for Disease Control

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