MERS CoV and Dentistry

By Noel Kelsch RDH, RDHAP, AS, BS

Understanding and comprehending the nature of a disease are essential parts of any infection control program. One disease that the Centers for Disease Control and Prevention (CDC) wants all health care providers to be aware of and stay up to date on is call Middle East Respiratory Syndrome Coronavirus (MERS-CoV).¹

What is this disease? According Organization for Safety, Asepsis and Prevention (OSAP), coronavirus gets its named for the crown like spikes on the surface of the virus. This is a pretty common virus, and most people around the world will get this virus sometime in their lifetime. In humans it, causes mild to moderate upper-respiratory tract illnesses.²

A novel form of coronavirus is MERS-CoV. This nasty little virus has symptoms that go far beyond coronavirus. The most common symptoms observed are fever, cough, and breathing difficulties. Most will develop severe acute respiratory illness with the above symptoms, including shortness of breath. Some people were reported as having a mild respiratory illness, and others may get no symptoms at all. Pneumonia, kidney failure, and immune-suppression have resulted. The shocking results are that 30% of them died.^1,3

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See related article

OSAP launches online MERS toolkit

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This virus is thought to be new to humans and was first reported in Saudi Arabia in 2012.⁴ Currently, there are three confirmed cases in the United States with two additional cases involving health-care providers being investigated. The first two confirmed cases were separate travelers on different dates from Saudi Arabia to the United States. The third case does not involve symptoms nor does it involve travel outside the United States. The third patient was exposed to one of the travelers who had the active virus. It is currently reported that the only direct contact they had was shaking hands.⁵

The CDC reported that “the Illinois resident … laboratory test results showed apparent past MERS-CoV infection.” These laboratory test results are preliminary and suggest that he probably got the virus from the patient he was exposed to and the person’s body developed antibodies to fight the virus.

“This latest development does not change CDC’s current recommendations to prevent the spread of MERS,” said Dr. David Swerdlow, who is leading CDC’s MERS-CoV response. “It’s possible that as the investigation continues others may also test positive for MERS-CoV infection but not get sick. Along with state and local health experts, CDC will investigate those initial cases and if new information is learned that requires us to change our prevention recommendations, we can do so.”³

This report brings the total of 570 confirmed cases of MERS in 18 countries, and 171 people have died. Up to 20% of these cases have involved health-care workers.^4,5

The CDC is continuing to investigate and respond to the changing situation to prevent the spread of MERS-CoV in the United States. At this time, they report that these three cases are a very low risk to the general public in the United States.

The hardest part of this disease is the fact that the mode of transmission is still not identified. Thus far, all human-to-human transmission has occurred either in a household, work environment, or health-care setting. The virus is thought to be of animal origin but so far it has not been identified in any animal species. The specific types of exposures that result in infection are still a mystery. Recently, there have been an increased number of reports of health-care associated infections, including those two U.S. health-care providers. In some communities, people have become ill but no potential source of infection has been found. It is possible that these persons were infected by exposure to an animal or perhaps another source or person.⁶

There is no available vaccine or specific treatment recommended for the virus. Treatment is supportive based on the patient’s symptoms. All cases identified so far have had either a direct or indirect connection with the Middle East. However, some cases identified in recent travelers from the Middle East have resulted in local, unsustained transmission to close contacts.²

Those at the highest risk are those with close contact to a case, defined as any person who provided care for a patient, including a health-care provider or family member not adhering to recommended infection control precautions (such as not wearing recommended personal protective equipment), or had similarly close physical contact, or any person who stayed at the same place (for example, lived with or visited) as the patient while the patient was ill.¹

So what do dental health care professionals need to do?

Because transmission has occurred in health‐care facilities in several countries, including from patients to health‐care providers, infection control is vital. It is not always possible to identify patients with MERS‐CoV early or without testing because symptoms and other clinical features may be nonspecific. For this reason, it is important that health‐care workers apply standard precautions consistently with all patients.⁶

The CDC gives the following standards for all of us to follow to help prevent exposure:

Evaluate all patients — As with any quick diagnosis of a disease, isolation and care will impact the outcome of survival and spreading of the disease. Do not allow sick patients to enter the dental setting. Health-care providers should be alert for and evaluate patients for MERS-CoV infection who:

1. Develop severe acute lower respiratory illness within 14 days after traveling from countries in or near the Arabian Peninsula, excluding those who only transited at airports in the region; or
2. Are close contacts of a symptomatic recent traveler from this area who has fever and acute respiratory illness; or
3. Are close contacts of a confirmed case? For these patients, testing for MERS-CoV and other respiratory pathogens can be done simultaneously. Positive results for another respiratory pathogen (H1N1 influenza, for example) should not necessarily preclude testing for MERS-CoV because co-infection can occur.

Adhere to infection control with all patients — Additional information and updates for evaluation of patients is available at: ihttp://www.cdc.gov/coronavirus/mers/interim-guidance.html. Health-care providers should contact their state or local health department if they have any questions. The CDC recommends that all close contacts of a confirmed or probable case of MERS while the case was ill should be evaluated in consultation with state and local health departments.

Other contacts of the ill person, such as community contacts or contacts on conveyances (for example, airplane or bus) should also be evaluated in consultation with state and local health departments. Ill people who are being evaluated for MERS-CoV infection and do not require hospitalization for medical reasons may be cared for and isolated in their home and kept away from anyone who is not ill.⁴

Health-care providers should adhere to recommended infection-control measures, including standard, contact, and airborne precautions, while managing symptomatic contacts and patients who are persons under investigation or who have probable or confirmed MERS-CoV infections.

For CDC guidance on MERS-CoV infection control in healthcare settings, see Interim Infection Prevention and Control Recommendations for Hospitalized Patients with MERS-CoV at http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html.

If patients in the dental setting present with these symptoms, dental treatment should be postponed, if possible, and emergency cases that must be delivered in an environment with proper are exchange, proper mask filtration, etc., as listed at the above link. It is important to note that droplet precautions should be added to standard precautions when providing care to all patients with symptoms of acute respiratory infection if they are being treated for an emergency in the dental setting.⁶

Contact precautions and eye protection should be added when caring for suspected or confirmed cases of MERS‐CoV infection. Airborne precautions should be applied when performing aerosol‐generating procedures.

Infection Control Precautions For Emergency Dental Treatment

Treatment should be postponed if patients are exhibiting symptoms of this disease. If there is an emergency and aerosols are anticipated:

• Wear a particulate respirator when putting on a disposable particulate respirator, always check the seal
• Wear eye protection (i.e. goggles or a face shield)
• Wear a clean, non-sterile, long-sleeved gown and gloves
• Wear an impermeable apron for some procedures with expected high fluid volumes that might penetrate the gown
• Perform procedures in an adequately ventilated room; i.e. minimum of 6 to 12 air changes per hour in facilities with a mechanically ventilated room and at least 60 liters/second/patient in facilities with natural ventilation (this will generally be a hospital operatory setting)
• Limit the number of persons present in the room to the absolute minimum required for the patient’s care and support
• Perform hand hygiene before and after contact with the patient and his or her surroundings and after PPE removal.

NOEL BRANDON KELSCH, RDHAP, is a syndicated columnist, writer, speaker, and cartoonist. She serves on the editorial review committee for the Organization for Safety, Asepsis and Prevention newsletter and has received many national awards. Kelsch owns her dental hygiene practice that focuses on access to care for all and helps facilitate the Simi Valley Free Dental Clinic. She has devoted much of her 35 years in dentistry to educating people about the devastating effects of methamphetamines and drug use. She is a past president of the California Dental Hygienists' Association.

Resources for the dental setting

For more information, for consultation, or to report possible cases, contact the CDC Emergency Operations Center at (770) 488-7100.

For information on the disease and specifics on current prevention measures go to OSAPS TOOL KIT

References

1. http://www.cdc.gov/coronavirus/mers/faq.html Accessed 5/12/14
2. http://www.osap.org/?page=CoronaVirusToolkit Accessed 5/12/14
3. http://www.cdc.gov/media/releases/2014/p0517-mers.html Accessed 5/19/14
4. http://www.cdc.gov/coronavirus/mers/hcp/home-care.html Accessed 5/12/14
5. http://www.advisory.com/daily-briefing/2014/05/19/us-reports-first-person-to-person-mers-transmission Accessed 5/19/14
6. http://www.who.int/csr/disease/coronavirus_infections/faq/en/ Accessed 5/12/14
7. http://www.who.int/csr/disease/coronavirus_infections/IPCnCoVguidance_06May13.pdf Accessed 5/12/14