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State of California—Health and Human Services Agency
California Department of Public Health

AFL 13-13
May 29, 2013

All Health Facilities

Middle East Respiratory Syndrome Coronavirus-Health Alert

The California Department of Public Health (CDPH) is dedicated to protecting the health and well-being of the people in California. There have been recent reports of healthcare-associated transmission of a novel coronavirus, now known as Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in several countries. CDPH is distributing the latest Centers for Disease Control and Prevention (CDC) information regarding novel coronavirus which includes heightened surveillance, infection control, and laboratory precautions to prevent the spread of this novel virus.

In September 2012, the World Health Organization announced the discovery of MERS-CoV in a patient who died with an acute respiratory distress syndrome in Saudi Arabia. To date, MERS-CoV has been identified in 49 persons in seven countries (Saudi Arabia, Qatar, Jordan, the United Kingdom, the United Arab Emirates, France, and Tunisia). The infected persons in the Europe and Tunisia had either traveled to an Arabian Peninsula country or had contact with someone infected with MERS-CoV. All infected persons have been adults and most have co-morbidities. Their symptoms included fever, cough and shortness of breath. Most patients have been severely ill and 27 (more than 50 percent) have died. Two persons experienced only mild respiratory illness.

Person-to-person transmission of MERS-CoV has now been documented. Since the beginning of May 2013 a total of 21 cases of MERS-CoV infection, nine of which were fatal, have been reported from an outbreak primarily linked to a healthcare facility in Saudi Arabia. On May 15, MERS-CoV infection was confirmed in two healthcare workers exposed to MERS-CoV-infected patients. In addition, healthcare-associated transmission to the roommate of a MERS-CoV patient occurred in France. No cases of MERS-CoV have been identified in the United States to date. However, with the ease of international travel and the potential for this virus to be transmitted in healthcare settings, CDC is encouraging healthcare facilities to:

  • Review their preparedness plans, including their respiratory protection program and Aerosol Transmissible Diseases (ATD) exposure control plans;
  • Take steps to ensure that persons presenting with severe acute respiratory illness are evaluated for history of recent travel;
  • Implement appropriate infection control measures for suspect cases of MERS-CoV illness; and
  • Immediately report suspect MERS-CoV cases to their local health departments.

Patients who should be evaluated for novel coronavirus (nCoV) infection

The U.S. CDC is recommending surveillance and testing for persons who have unexplained severe respiratory illness and a history of travel to countries in the Arabian Peninsula or neighboring countries.* In particular persons who meet the following criteria should be reported and evaluated:

  • A person with an acute respiratory infection, which may include fever (≥ 38°C/100.4°F) and cough; and
  • Suspicion of pulmonary parenchymal disease (e.g., pneumonia or acute respiratory distress syndrome based on clinical or radiological evidence of consolidation); AND
  • History of travel from the Arabian Peninsula or neighboring countries* within 10 days of symptom onset; and
  • Whose illness is not already explained by any other infection or etiology, including all clinically indicated tests for community-acquired pneumonia** according to local management guidelines.

In addition, the following patients may be considered for evaluation of nCoV infection:

  • Persons who develop severe acute lower respiratory illness of known etiology within 10 days after travel from the Arabian Peninsula or neighboring countries* but do not respond to appropriate therapy; or 
  • Persons who develop severe acute lower respiratory illness who are close contacts of a symptomatic traveler who developed fever and acute respiratory illness within 10 days after travel from the Arabian Peninsula or neighboring countries.* Close contact is defined as providing care for the ill traveler (e.g., a healthcare worker or family member), or having similar close physical contact; or having stayed at the same place (e.g., lived with, visited) while the traveler was ill.

Infection control guidance for (nCoV) infection

The CDC recommends that infection control guidance developed for the coronavirus that caused Severe Acute Respiratory Symptom (SARS) be implemented for patients with confirmed or suspected MERS-CoV infection. Therefore, Airborne and Contact Precautions in addition to Standard Precautions (including eye protection), should be applied when caring for patients with confirmed or suspected MERS-CoV infection. CDC infection control guidance for SARS is available at: CDC - SARS Infection Control. Additionally, as employers, facilities are required to follow recommendations under the California Occupational Safety Health Administration’s (OSHA) ATD Standard Title 8 of the California Code of Regulations (CCR) Section 5199, found at: Title 8 CCR section 5199

Laboratory biosafety for (nCoV)

Unlike SARS, MERS-CoV appears to be isolated and propagated ‘relatively easily’ in viral tissue cultures. Therefore, CDC advises that viral isolation not be performed on specimens from suspect MERS-CoV cases (unless it is performed in a Biosafety Level-3 facility). Please see CDC laboratory guidance for the collection, handling, processing and transport of specimens from suspect novel coronavirus patients at:

CDC - Interim Guidelines for Collection, Processing and Transport of Clinical Speciments from Patients Under Investigation for MERS

CDC - Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with MERS

Laboratories are also required to follow recommendations under the laboratory section of OSHA ATD Standard, Title 8 CCR Section 5199, found under subsection (f) at:

Title 8 CCR section 5199

Please notify your local health department immediately if a patient is suspected to be infected with MERS-CoV. If appropriate, your local health department will work closely with the CDPH Viral and Rickettsial Disease Laboratory (VRDL) and the CDC to coordinate testing. Hospital laboratories should not attempt viral isolation from specimens on suspected cases.

In order to keep apprised of the up-to-date information on the MERS-CoV as well as the current CDC recommendations please visit the CDC website at:

CDC - MERS: Interim Patient under Investigation Guidance and Case Definitions

If you have any questions regarding the infection prevention and control of MERS-CoV, please contact the CDPH Healthcare Associated Infections (HAI) Program - Rebecca Siiteri, RN, MPH at or Kavita K. Trivedi, MD at



Original signed by Debby Rogers

Debby Rogers, RN, MS, FAEN
Deputy Director



​*Arabian Peninsula or neighboring countries include: Bahrain, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Palestinian territories, Oman, Qatar, Saudi Arabia, Syria, the United Arab Emirates, and Yemen.

**Examples of respiratory pathogens causing community-acquired pneumonia include influenza A and B, respiratory syncytial virus, Streptococcus pneumoniae, and Legionella pneumophila.


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