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MERS-CoV and Dentistry

By Noel Brandon Kelsch, RDHAP

Understanding the nature of a disease is an essential part 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 called Middle East Respiratory Syndrome Coronavirus (MERS-CoV).1

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

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A novel form of coronavirus is MERS-CoV. This nasty little virus's symptoms go far beyond coronavirus. The most common symptoms are fever, cough, and breathing difficulties. Most people will develop severe acute respiratory illness with symptoms of fever, cough, and shortness of breath. Some people reported having a mild respiratory illness, and others had no symptoms at all. Pneumonia, kidney failure, and immune suppression have also been reported. The shocking results are that 30% of the people affected died.1,3

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

The CDC reports, "The Illinois resident's laboratory test results showed apparent past MERS-CoV infection." These laboratory results are preliminary and suggest that the person probably caught the virus from the person he was exposed to, and his body developed antibodies to fight the virus.

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

This brings the total to 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 U.S. At this time they report that these three cases are a very low risk to the general American public.

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 lead to infection are still a mystery. Recently, there have been an increased number of reports of health-care-associated infections, including the two health-care providers in the U.S. In some communities, people have become ill, but no potential source of infection has been found. It is possible that these people were infected by exposure to an animal, or 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 a direct or indirect connection with the Middle East. However, some cases identified in recent travelers from the Middle East have resulted in local, nonsustained transmission to close contacts.2

Those at the highest risk are people with close contact to a case, defined as any person who provided care to a patient, including a health-care provider or family member not adhering to the recommended infection control precautions (i.e., not wearing personal protective equipment), or any person who stayed at the same place (e.g., lived with, visited) with 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 for health‐care workers to 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 disease, quick diagnosis, isolation, and care will impact the outcome of survival and spread of the disease. Do not allow sick patients to enter the dental setting. Health-care providers should be alert for and should evaluate patients for MERS-CoV infection who:

  • Develop severe acute lower respiratory illness within 14 days after traveling from countries in or near the Arabian Peninsula, excluding those who only traveled to airports in the region; or
  • Are close contacts of a symptomatic recent traveler from the area who has fever and acute respiratory illness; or
  • 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 (e.g., H1N1 influenza) 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 cdc.gov/coronavirus/mers/interim-guidance.html. Health-care providers should contact their state or local health departments with any questions. The CDC recommends that all close contacts of a confirmed or probable case of MERS 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 (e.g., airplane, 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 may be isolated and cared for in their homes and kept away from healthy people.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 under investigation or who have probable or confirmed MERS-CoV infections.

For CDC guidance on MERS-CoV infection control in health-care settings, see Interim Infection Prevention and Control Recommendations for Hospitalized Patients with MERS-CoV at 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. Emergency treatment must be delivered in an environment with proper air 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 setting6 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.

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 OSAP'S Tool Kit (osap.org/default.asp?page=CoronaVirusToolkit).

Resources For The Dental Setting

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, 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 six 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.7

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.

References

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

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