Decision No. 2174/QD-BYT dated June 08, 2015 of the Ministry of Health guiding the supervision and prevention/response against middle east respiratory syndrome coronavirus (MERS-COV)

THE MINISTRY OF HEALTH

Decision No.2174/QD-BYT datedJune 08, 2015 of the Ministry of Health guiding the supervision and prevention/response against Middle East Respiratory Syndrome Coronavirus (MERS-COV)

Pursuant to the Decree No. 63/2012/NĐ-CP dated August 31, 2012 by the Government defining the functions, tasks, entitlements and organizational structure of the Ministry of Health;

At the request of the Director of General Department of Preventive Medicine, the Ministry of Health,

DECIDES:

Article 1.To enclose with this Decision the "Guidelines for supervision and prevention/response against the Middle East Respiratory Syndrome coronavirus (MERS-CoV)".

Article 2."Guidelines for supervision and prevention/response against the Middle East Respiratory Syndrome coronavirus (MERS-CoV)" is a guiding document applicable in preventive healthcare facilities and the state or private medical examination and treatment facilities nationwide.

Article 3.The Decision comes into effect from the day it is promulgated. The Decision replaces the Decision No.2002/QĐ-BYT dated 06/6/2014 by the Minister of Health.

Article 4.The Chiefs of the Ministry Office; the Chiefs Ministry Inspector; Directors of Departments, Director Generals of Departments and Directorates affiliated to the Ministry of Health; Directors of Institutes of Hygiene and Epidemiology and Pasteur Institutes; Directors of medical examination and treatment facilities affiliated to the Ministry of Health; Directors of the Department of Health; Directors of medical preventive centers, Centers for International Health Quarantine, medical examination and treatment facilities of provinces; Heads of medical agencies affiliated to Ministries/sectors and Heads of relevant units are responsible for implementing this Decision./.

For the Minister

The Deputy Minister

Nguyen Thanh Long

GUIDELINES

FOR SUPERVISION AND PREVENTION/RESPONSE AGAINST THE MIDDLE EAST RESPIRATORY SYNDROME CORONAVIRUS (MERS-COV)
(Enclosed with the Decision No. 2174/QĐ-BYT dated June 08, 2015 by the Minister of Health)

I. GENERAL CHARACTERISTICS

Middle East Respiratory Syndrome coronavirus (MERS-CoV) is a clade A infectious diseases caused by a new member of the group of coronavirus. MERS-CoV was first reported in Saudi Arabia in April 2012. Up to June 06, 2015, WHO has notified of 1,195 cases of infection, including 448 related deaths in 26 countries, mainly in Middle East area and some other countries, including Asian countries. MERS-CoV virus appears to have originated in bats and infected camels, then camels become main virus carriers transmitting viruses to human. MERS-CoV can be transmitted from people to people who are in close contact with patients, mainly by direct contact with infectious respiratory secretions of a confirmed or probable case. The incubation period for MERS is about 2 to 14 days. Infected person may have minor symptoms like fever, cough or serious symptoms like dyspnea, pneumonia, respiratory failure, possibly accompany gastrointestinal symptoms like diarrhoea that potentially lead to organ failure, especially renal failure, entailing high risk of death. About 35 to 40 of every 100 people have been infected or died. Some infected people had mild symptoms or no symptoms at all, causing difficulty to the discovery of MERS-CoV. Currently, there is no vaccine or specific antiviral treatment recommended for MERS-CoV infection.

II. GUIDELINES FOR SUPERVISION

1. Definition of infection cases

1.1. Probable cases

A person is probable for infection if he/she presented the following signs:

- Fever and

- Respiratory tract infections like cough, dyspnea, pneumonia, respiratory failure, etc., and

- Perform any of the following epidemiological activities within 14 days before the patient get ill:

+ Stay or travel to/from a country with MERS-CoV, or

+ Have close contact with people with confirmed MERS-CoV infection, or

+ Have close contact with people with acute respiratory infection concerning a country with epidemic, or

+ Have close contact with a group of people with acute respiratory infection that is probably caused by Mers-CoV.

“Close contact” includes the following cases:

+ People who directly provide care/treatment for or live/work/receive treatment in the same room/area with people having a confirmed MERS-CoV infection, family of infected people;

+ People who sit next to people with confirmed MERS-CoV infection on a trip/flight;

+ People who have direct contact with people having confirmed MERS-CoV infection in any situation.

1.2. Confirmed cases

Are cases in which people are evaluated and confirmed to have MERS-CoV infection.

2. Definition of epidemic hotspot0}

2.1. Epidemic hotspot:a small scale area in which at least 1 case of infection is confirmed.

2.2. Controlled hotspot:A hotspot is considered controlled when there is not any new infection case reported within 28 days from the last case.

3. Supervision contents

3.1. Situation 1:

Request: strictly supervise to promptly discover the first probable cases, quickly reach diagnosis and localize the epidemic area to handle promptly.

Supervision mode for such situation:

- At checkpoints: comply with the regulation on health declaration at international checkpoints according to the conditions of Vietnam and the international practice. Conduct screening examination to early discover probable cases at checkpoint areas; use body temperature measuring device, supervise the constitution, isolate the infected entities, collection information about epidemic profile, conduct preliminary examination and make a list of probable cases then transfer it to a medical facility for testing and management according to the regulation.

- In public and at medical facilities: carry out initiative supervision and inspection of the epidemic disease, collect specimens, formulate lists, manage and supervise every probable case.

3.2. Situation 2: An confirmed infection case is discovered in Vietnam

In this situation, it is necessary that the illness cases relating to the infection case shall be discovered early so that the hotspot can be handled thoroughly, avoiding spreading at medical facilities and in public.

Supervision mode for such situation:

- At checkpoints: continue the supervision as the provision for situation 1.

- In public and at medical facilities:

+ Intensify the initiative supervision and inspection of epidemic disease, formulate lists, collect specimens of every probable case.

+ Formulate list of people having close contact with infected people, carry out management and supervision of their health conditions within 14 days from the last contact with the infected person.

+ Collect specimens of people who are in close contact with the infected person on the basis of inspection on site.

3.3. Situation 3: MERS-CoV spreads out

In this situation, it is necessary that the new infection cases shall be discovered early so that epidemic hotspot can be handled thoroughly, minimizing the spread of epidemic disease in public and at medical facilities.

Supervision mode for such situation:

- At checkpoints: continue the supervision as the provision for situation 1.

- In public and at medical facilities:

+ Regarding areas without confirmed infection cases: conduct supervision actively and initiatively; conduct inspection and scanning, formulate lists and collect specimens of every probable cases.

+ Regarding confirmed epidemic hotspots: intensify the supervision; conduct inspection and scanning, formulate lists and carry out management of all probable cases; collect specimens of at least 3-5 first probable cases. Any people living in the epidemic hotspot that has similar symptoms is considered confirmed infection cases and shall be handled according to the regulation.

In both 3 situations, any death that is considered caused by MERS-CoV shall be inspected and reported. Healthcare officers shall collect specimens of such case for testing and handling like a confirmed case.

3.4. Collection, storage and transport of specimens:Specified in Appendix 1 enclosed herewith.

3.5. Notification and report

- Authorized agencies shall make notification and report on clade A infectious diseases according to the regulation in the Law on prevention and treatment of infectious diseases; the Circular No. 48/2010/TT-BYT dated December 31, 2010 by the Ministry of Health and other documents on notification and report on epidemic diseases.

- Reports on MERS-CoV cases shall conform to the form No. 1.

- Reports on deaths from MERS-CoV shall conform to the form No. 2.

- MERS-CoV inspection paper shall conform to the form No. 3.

III. PROPHYLACTIC MEASURES

1.  Unspecific prophylactic measures

- Provide the citizens, medical staff, inbound and outbound passengers, public service staff (air transport, entry and exit, passenger transport, tourist, etc.) about MERS-CoV and prophylactic measures, initiatively supervise the symptoms and report to healthcare offices the issues relating to MERS-CoV, especially people who travel from/to a country having MERS-CoV infection cases.

- Avoid going to areas having MERS-CoV infection cases unless necessary, especially people with chronic diseases like diabetes mellitus, chronic pulmonary disease, immunodeficiency. People who travel to an area having MERS-CoV infection cases shall learn about the information on the disease situation of such area to avoid infection; initiatively mention about the travel, monitor health condition for 14 days and promptly notify the healthcare offices of the development of a fever and/or other probable symptoms;

- People having symptoms of respiratory illness or likely to have been infected with symptoms like fever, cough, dyspnea shall not go travel or go to crowded place;

- Avoid contact with people with acute respiratory infection. People who are in contact with patients shall wear a surgical mask and avoid close contact;

- Cover nose and mouth with a handkerchief when cough or sneeze to reduce the dispersion of respiratory infectious secretions, then wash the used handkerchief or throw it in the trash;

- Wash hands often and thoroughly with soap and water, avoid touching eyes, nose, and mouth with unwashed hands;

- Increase he ventilation at workplaces, houses, schools, medical facilities, etc. by opening all the doors and windows, avoid using air-conditioners;

- Clean the floor, doorknobs and surfaces of household items with common cleansers like soaps and disinfectants;

- Promote health with rational diet and daily activities;

- Notify the nearest medical facility of the symptoms of acute respiratory infection, especially people relating to epidemic for prompt advise, isolation and treatment;

- Visit regularly the websiteshttp://moh.gov.vn,http://vncdc.gov.vnand other official sources for updated information about the MERS-CoV diseases and prevention and treatment against MERS-CoV.

2. Specific prophylactic measures

Currently, there is no vaccine or specific treatment recommended for MERS-CoV infection

3. Preparation of facilities, chemicals and preventive equipment when the epidemic disease is confirmed

- Protective equipment, medical equipment, emergency and treating medicine;

- Chemicals and biological products for testing;

- Disinfectants;

- Chemical sprayers;

- Isolation areas.

IV. MERS-CoV PREVENTIVE MEASURES

1. Continue the prophylactic measures specified in part III

2. Take the following measures

2.1. Regarding people confirmed to have, or being evaluated for, MERS-CoV infection

- Carry isolation and provide treatment at medical facilities, minimize the complication, death and infection in hospitals. Duration of isolation shall conform to the regulation of the Ministry of Health.

- Wear the surgical mask correctly when being in contact with other people to avoid infection.

- Provide treatment according to the guidance of the Ministry of Health.

- Cadavers shall be handled according to the Circular No. 02/2009/TT-BYT dated May 26, 2009 by the Minister of Health.

2.2. Regarding close contacts and else

- Caregivers shall take personal protective measures like wearing surgical mask, eye protection, gloves, gowns, etc. while having close contact with patients; wash hand with soap or disinfectant immediately after having contact with the patients.

- Minimize the contacts with infected people.

- Ensure personal hygiene, wash hand often with soap; gargle with antiseptic mouthwash.

- Avoid coming to crowded place to avoid infection to other people.

To carry out the management, supervision, isolation and apply the appropriate prophylactic measures for people who have close contact with a confirmed or probable case of MERS, local preventive healthcare facilities shall:

- Formulate the list of people having close contact with infected people, carry out management and supervision of health conditions within 14 days from the last exposure to the infected people.  Give people having close contact with infected people guidance on the symptoms and prophylactic measures so that they can supervise and promptly discover the symptoms of acute respiratory infection. Any symptoms of the infection shall be notified to the nearest medical facility for isolation and prompt treatment.

- Regarding other contacts with a confirmed or probable case of MERS (travel on the same flight/trip or attend the same meetings, etc.), healthcare offices shall post announcement on means of mass media so that the citizens can supervise themselves and notify the healthcare offices about the symptoms of infection.

2.3. Regarding household members

- Take the prophylactic measures specified in section 1 part III.

- Keep the house clear, clean the floor, doorknobs and surfaces of household items often with common cleansers like soaps and disinfectants.

2.4. Regarding the public, schools, factories and offices

- Take also the preventive measures applicable to households.

- The decision on the close a school, office, factory, etc. shall be issue by epidemic control steering committee of provinces on the basis of the conditions of specific areas and the effect of the decision to the reduction of the spread of the disease and the impact of it socio-economic development.

2.5. Prevention in healthcare facilities

Divide strictly people for examination, isolation and treatment; take measures for bacterial contamination control on healthcare officials, caregivers and other patients (who are not confirmed to have or being evaluated for MERS-CoV infection) at healthcare facilities according to the guidance of the Ministry of Health to avoid the infection.

2.6. Decontamination and treatment for hotspot’s environment

- Isolation areas and houses of infected people shall be decontaminated by cleaning the floor, doorknobs and surfaces of household items with solution containing 0.5% active chlorine. The decontamination of other relevant areas shall be under the management of epidemiological officials on the basis of inspection on site.

-Respiratory secretions (sputum, saliva, rhinopharyngitis, bronchial secretions, etc.) of infected people shall be thoroughly treated with solution containing 1.25% active Chlorine in a ratio of 1:1 within at least 30 minutes then collected according to the regulation of the healthcare facility.

- Clothing, bedding and things used by an infected person when he/she suffers from infection shall be soaked in solution containing 0.5% active Chlorine for 1-2 hours before washing.

- Household items in patient’s house shall be decontaminated with solution containing 0.5% active Chlorine.

- Vehicles for carrying infected people shall be decontaminated with solution containing 0.5% active Chlorine.

The Ministry of Health will update and adjust the guidance according to the development of MERS-CoV and the recommendation of WHO.

APPENDIX 1

COLLECTION, STORAGE AND TRANSPORT OF SPECIMENS

1.Pathology specimens

Specimens for MERS-CoV testing shall be collected by healthcare workers who have completed the training in biosafety. Collected specimens shall include at least 2 pathology specimens, including 01 respiratory specimen and 01 blood specimen, including:

- Respiratory specimens:

Specimens collected from lower respiratory tract are reported having higher virus concentration than those collected from upper respiratory tract and have a higher sensitivity for the diagnosis of MERS-CoV.

+ Specimens of lower respiratory tract:

·   Sputum

·   Alveolate secretions, endotracheal secretions, pleural effusion, etc.;

·   Organization of lung, bronchi, alveoli.

+ Specimens of upper respiratory tract shall be collected only when the healthcare workers fail to collect specimens of lower respiratory tract.

·   Nasopharyngeal secretions;

·   Mixture of rhinopharyngitis and oropharyngeal secretions

·   Nasal cavity irrigating solution.

- Blood specimens (3-5 ml venous blood, with or without ethylene diamine tetra acetate – EDTA)

+ Blood specimens taken during acute phase, when the patients have just gone into hospital.

+ Blood specimens taken during recovery phase (at least 3 weeks after the illness develops).

2. Time of collection of specimens

Respiratory specimens shall be collected as soon as possible since the illness develops (ideally within 7 days and before using antiviral medicine)

3. Collection of specimens

3.1. Preparation

- Soft swabs with plastic or metal handles (swabs with wood handles must not be used because they possibly contain a substance that may abrogate the ability of some viruses, affecting the accuracy of PCR testing).

- Nasopharyngeal secretions collecting equipment.

- 15 ml conical centrifuge tubes, containing 2-3 ml of specimens’ transporting and storing environment.

- Falcon 50ml conical centrifuge tubes or nylon bags to package the specimens.

- Bandages and compresses with germicide.

- Medicinal alcohol, pens, etc.

- Protective clothing.

- Eye protection.

- Gloves

- N95 respirators.

- Sterilized 10 ml syringes.

- Sterilized tubes (with or without EDTA).

-Garrot bandage, cotton wool, alcohol, etc.

- Cold boxes for storing specimens.

3.2. Progress

3.2.1. Use of protective clothing

3.2.2. Specimen collection technique

a. Rhinopharyngitis and oropharyngeal secretions

- Rhinopharyngitis: request the patient to turn his/her face 45° upward. Put the swab along the floor of nasal cavity to nasopharyngeal tonsil, wait until the swab absorbs salpharyngeal secretions then rotate and press it into the wall of nasal cavity and take it out slowly.

- Oropharyngeal secretions: request the patient to open his/her mouth, use a tongue depressor to depress the tongue down. Put the swab deeply into oropharynx and press it toward the posterior pharynx.

- Rhinopharyngitis swabs and oropharyngeal swabs can be kept in the same vial containing 2-3 ml of specimens’ transporting and storing environment (heads of swabs shall be submerged).

b. Nasal cavity irrigating solution

Give explanation so that  the patient cooperates well with specimen taker. Pump 10 ml of irrigating solution (physiological saline) into the patient’s nose, request the patient not to swallow. The collected solution shall be kept in a glass beaker or a petri dish and pour 2-3 ml into the specimens’ transporting and storing environment.

c. Nasopharyngeal secretions

Nasopharyngeal secretions shall be collected with specialized collecting equipment containing 2 tubes (a catheter and 1 tube closely attached to vacuum machine).

Request the patient to turn his/her face 45° upward, put the catheter into the patient’s nose parallel to the palate to the middle point of nose side and the earflap of the same side, start the vacuum machine then rotate and take the catheter out carefully.

Transfer the nasopharyngeal secretions into specimens’ storing and transporting environment.

d. Sputum

Request the patient to gargle with physiological saline then spit it strongly out to the containing equipment (sterilized glass). Transfer the specimen into specimens’ storing and transporting environment.

e. Endotracheal secretions

The patient shall be breathing artificially and shall have been intubated endotrachea. Put a secretion aspirating tube along the endotrachea and use a syringe to aspirate the endotracheal secretions through the tube.  Put the endotracheal secretions into specimens’ transporting and storing environment.

f. Blood specimens

Take 3-5ml venous blood with a sterilized tubular needle and put it into a vial (with or without EDTA) that is stored at 4°C for 24 hours.

Notes:

- Name, age, address of patient, type of specimen and date of collect shall be written on cover of specimen containing vials

- The collection of specimens from lower respiratory tract (endotracheal secretions, aveolate secretions, pleural effusion) shall be with the advice of clinician.

3.2.3. Decontamination of medical tools and disinfection of specimen collecting areas

All protective clothing and used tools shall be put in a hospital bag that is impervious to high temperature, using new gloves and surgical masks.

Such bag shall be tied tight and wet dried at 120°C for 30 minutes before disposal.

Hospital workers shall wash their hands with soap; all tools and areas serving collection of specimens and cold boxes used for transporting specimens to the laboratory shall be decontaminated with 0.1% active Chlorine.

4.Storage, packaging and transport of specimens to the laboratory and notification of results

4.1. Storage

Collected specimens shall be transported to the laboratory within the shortest time, specifically as follows:

- Any specimen shall be stored at 2-8°C and shall be transported to the laboratory within 48 hours since it is collected.

- Otherwise, the specimen shall be stored at -70°C right after it is collected.

- Specimens shall not be stored in the freezer of a fridge or stored at -20°C.

- Specimens being serum or plasma may be stored at 4°C for a week.

4.2. Packaging of specimens

Specimens shall be packaged carefully (3 layers) according to the regulation of WHO before transport.

- Any vials containing specimens shall have its lid fitted tightly and shall be packaged with a paraffin paper and a blotting paper.

- These vials shall be put into a bag (or a jar with fitted lid).

- Package these bags with blotting paper or absorbent cotton wool containing disinfectants (Chloramine-B, etc.) then put them into another nylon bag and tie tight.

- Specimen collection papers shall be contained in the last-layer nylon bags and tied tight. Such bags shall be put into the cold boxes having the logos of WHO outside (logo for biospecimen and the right-way-up logo).

4.3. Units in charge of receiving and testing; transport of specimens

4.3.1. Units in charge of receiving and testing specimens

- Units authorized to receive specimens and conduct testing:

+ Laboratory of National Institutes of Hygiene and Epidemiology;

+ Laboratory of Ho Chi Minh City Institutes of Hygiene and Epidemiology;

+ Laboratory of National Hospital for Tropical Diseases;

+ Laboratory of Ho Chi Minh City Hospital for Tropical Diseases;

- Units authorized to receive specimens from local areas:

+ Laboratory of National Institutes of Hygiene and Epidemiology is in charge of receiving specimens sent from provinces from Quang Ngai and northward.

+ Laboratory of National Institutes of Hygiene and Epidemiology is in charge of receiving specimens sent from provinces from Binh Dinh and southward.

On the basis of the development of MERS-CoV epidemic and the capacity of the units, the Ministry of Health will consider widening the specimens receiving and testing points if necessary.

4.3.2. Transport of specimens

- Fill in the Form No. 4.

- Notify the laboratory about the date of dispatch and the expected date of arrival.

- Specimens shall be transported by road or by air as soon as possible.

- Strictly prevent specimen containing vials from breaking during the transport.

- Specimens shall be stored at 4°C when transporting to the laboratory, avoiding melting-freezing repeatedly that reduce the quality of specimens.

4.3.3. Notification of testing results

When testing result is achieved, the testing authority shall immediately notify the General Department of Preventive Medicine, Institutes of Hygiene and Epidemiology and Pasteur Institutes in local area and the specimen sending units of the result at the earliest time using the form No. 5.