I don’t know if you have been following the MERS outbreak in the news but it does raise some concern. The CDC issued a MERS advisory yesterday. July 11, 2015 ABC news story covering CDC announcement of MERS outbreak status.

There are several animal and avian viruses that show the potential of becoming easily transmissible to humans. MERS, H7N9 and H5N1 are already spreading in humans, although not easily. The last major jump from animal to human occurred with the 1918 flu pandemic where an estimated 40 million people died. Mortality from MERS is currently 330-40% in the Middle East and 10% in South Korea. As health care workers, how we approach infectious disease precautions will have a lot to do with how safe we and our patients are in the workplace.

MERS (Middle Eastern Respiratory Virus) is a SARS-like corona virus. Since 2012 the outbreak has progressed from:

• just a camel virus from camels to camel in the Middle East
• then spreading from camels to people in the Middle East:
• then spreading from the rare infected person to close personal contacts in the Middle East to date in the Middle East there have 1440 cases to date with 444 deaths
• Now it’s appeared in South Korea with an infected apparent “super spreader” coming from the Middle East to S Korea infecting multiple people in 3 hospitals— 122 as of today with 11 deaths
• Just announced there is evidence of more person to person spread. In others words infected person to another person who then spread it to a third person. Not easily —yet

Note these are statistics from June 15, 2015 and they will change over time.

Clearly this is an animal virus that is potentially about to jump species. The last major jump from animal to human occurred with the 1918 flu pandemic where an estimated 40 million people died. In the Middle East the MERS mortality is 30-40%.

This overall mortality estimate may be  high because in South Korea it is only about 10%. This may mean that they are only diagnosing the folks who are sick enough to be hospitalized in the Middle East but are not diagnosing and therefore missing the milder infections. We don’t know yet. In addition to MERS, there are several versions of avian flu that are decimating poultry flocks globally, some of which are starting to infect people such as H7N9 and H5N1.

Why am I bringing this up? Well, we in San Diego have many people that travel to and from the Middle East because of the military and war effort support. We have brisk travel to and from Asia as well. We in anesthesia intubate people with respiratory failure from sometimes unknown agents all the time.

It’s not uncommon for anesthesia providers to run to the ICU to intubate patients with pneumonia or ARDS without wearing a mask. It is also common to see nurses and respiratory therapists, HCWs who would not think of suctioning an airway without wearing gloves or eye protection, to assist us in that intubation without donning a mask or eye protection. This is an unsafe practice.

Just to remind people about statistics from the 2003 SARS epidemic in 2003, aerosol-generating procedures such as endotracheal intubation, manipulation of an oxygen mask, suction before intubation and non-invasive ventilation carried the highest risks of SARS transmission to HCWs. A recent article in the on-line publication of the University of Minnesota Center For Infectious Disease Research and Policy (CIDRAP) states:

“Twenty-two percent of SARS patients in Hong Kong were HCWs.
Nosocomial outbreaks of SARS resulted, overall, in 716 secondary and tertiary cases and 52% (410) of these were in HCWs. HCWs with the highest risk of SARS infection were those performing tracheal intubations, working in wards with artificial central ventilation, having face-to-face interactions with SARS patients, wearing single (vs double) gloves, and caring for a ‘super-spreader’ cases.”

According to that CIDRAP article, which is last years statistics:

“As of May 6, [2014] 96 (19%) of the 495 known Middle East respiratory syndrome coronavirus (MERS-CoV) cases, including a number of fatalities, were in healthcare workers (HCWs).The vast majority of HCW cases—74%—have occurred in the Kingdom of Saudi Arabia, with 24% in the United Arab Emirates. Sixty-three HCW cases—or almost two thirds—were reported last month alone, and more than 60% of the 128 recent MERS patients in Jeddah were infected in a hospital, including 39 HCWs, 6 of whom required intensive care or died.”

Regular surgical masks are not very efficient at screening out particulates because they almost invariably leak around the edges. Testing shows 30-50 % of particles will leak into the face piece of a well fitting surgical mask, but this better than no mask at all. The N95 filter masks, when well fitted, allow less than 10% leakage.I am going to suggest that we all start following CDC recommendations for self protection when intubating respiratory cases in the ICU. These include:

When you go to the ICU or  the emergency room (or wherever you are doing an emergency intubation),

• Put on a mask if you’re managing the airway of a patient with respiratory illness. N95 is better than a regular mask, but any mask is better than no mask. This includes suctioning, etc. after the intubation.
• Wear gloves
• Wear eye protection (your glasses don’t count)
• Consider wearing a cover gown if the patient is infectious or the cause is unknown.
• Wash your hands, or use an alcohol-based prep before and after every patient contact.
• Be careful with contaminated equipment you really don’t want to stick that used laryngoscope blade in your pocket to take back to the department.
• If you use video laryngoscopy equipment like a glidescope, don’t stick the dirty glidescope blade back in the carry basket with the clean ones- even if it is in a protective sleeve
• Wipe down the glidescope when you bring it back warn any techs that help you maintain the equipment to glove if you have them clean it
• If you see a colleague being incautious, point it out.

There is no doubt that someday we will have another pandemic. It may not be MERS or avian flu. Last month someone came to work with a bad cold and before the week was out 20% of my department had it—several sick enough that that had to stay home. This is a depressing warning that we are not being as careful as we should with our everyday germs. If we do get a pandemic we are on the airway frontline and therefore according to the statistics are at highest risk of getting infected ourselves. We don’t want to be the victims. Let’s change our practice now.

I have been following outbreaknewstoday.com , an infectious disease site for updates, as well as the CDC website update page.

May The Force Be With You
Christine  Whitten
1. COMMENTARY: Protecting health workers from airborne MERS-CoV—learning from SARS, Lisa M Brosseau, ScD, and Rachael Jones, PhD ; May 19, 20142. Tran K, Cimon K, Severn M, et al. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PloS One 2012;7(4):e35797.