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

AFL 13-23
October 21, 2013

All Health Facilities

Health Alert Update - Middle East Respiratory Syndrome Coronavirus

​The California Department of Public Health (CDPH) is dedicated to protecting the health and well-being of the people in California. This All Facilities Letter (AFL) is being issued to provide updated information regarding the novel coronavirus known as Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and will replace the previously issued alert in AFL 13-13. CDPH is distributing the latest Centers for Disease Control and Prevention (CDC) information regarding MERS-CoV, which includes updates to the incubation period, heightened surveillance, patient evaluation, infection control, and laboratory precautions to prevent transmission 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 138 persons in eight countries (Saudi Arabia, Qatar, Jordan, Italy, the United Kingdom, the United Arab Emirates, France, and Tunisia). All cases have been directly or indirectly linked through travel to or residence in four countries: Saudi Arabia, Qatar, Jordan, and the United Arab Emirates. Symptoms include fever, cough and shortness of breath. Most patients have been severely ill and 60 (43 percent) have died. Although most reported cases involved severe respiratory illness requiring hospitalization, at least 27 (21 percent) involved mild or no symptoms.

Person-to-person transmission of MERS-CoV has been documented; however transmission does not appear to be sustained. Twenty-three (18 percent) cases occurred in healthcare workers. 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:

  • Ensure facility infection control policies are consistent with the Center for Disease Control and Prevention’s MERS-CoV guidance
    CDC - MERS Interim Infection Prevention and Control Recommendations;
  • Review procedures for rapidly implementing appropriate isolation and infection practices for potential MERS-CoV patients;
  • Review procedures for laboratory submission of specimens for MERS-CoV testing;
  • Monitor the situation at CDC’s MERS website;

A comprehensive checklist of CDC health care facility recommendations for MERs-coV is available at the following link:

CDC - MERS Healthcare Facility Preparedness Checklist

Patients who should be evaluated for MERS-CoV infection

Healthcare professionals should evaluate patients for MERS-CoV infection if they develop fever and pneumonia within 14 days after traveling from countries in or near the Arabian Peninsula.1 They should also evaluate patients for MERS-CoV infection if they have had close contact with a symptomatic recent traveler from this area who has fever and acute respiratory illness.

In particular, persons who meet the following criteria should be evaluated:

  • Fever (≥8°C, 100.4°F) and pneumonia or acute respiratory distress syndrome (based on clinical or radiological evidence);
    AND 1 of the following:
    • History of travel from countries in or near the Arabian Peninsula1 within 14 days before symptom onset;
    • Close contact with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula;*
    • Is a member of a cluster of patients with severe acute respiratory illness (e.g. fever and pneumonia requiring hospitalization) of unknown etiology in which MERS-CoV is being evaluated, in consultation with state and local health departments.

Patients who meet these criteria should also be evaluated for common causes of community-acquired pneumonia** Testing should be performed by molecular or antigen detection methods; viral cultures should not be performed. Positive results for another respiratory pathogen should not necessarily preclude testing for MERS-CoV. Testing for MERS-CoV and other respiratory pathogens can be done simultaneously. Additional testing guidance can be found at:

Interim Guidelines for Collecting, Handling, and Testing Clinical Speciments from Patients Under Investigation for MERS

Infection control guidance for MERS-CoV infection

Infection control remains a primary means of preventing and controlling MERS-CoV transmission. 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. Check lists of key actions that health-care providers and facilities can take to prepare for MERS-CoV patients can be found at:

CDC - MERS Preparedness

Additionally, as employers, facilities are required to follow recommendations under the California Occupational Safety Health Administration’s (Cal/OSHA) ATD Standard Title 8 of the California Code of Regulations (CCR) Section 5199, found at:

Section 5199. Aerosol Transmissible Diseases

Laboratory biosafety for MERS-CoV

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 Laboratory Biosafety Guidelines for Handling and Processing Speciments Associated with MERS

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

Section 5199. Aerosol Transmissible Diseases

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 - Interim Patient Under Investigation (PUI) 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 at 510-412-6060, or



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.

** Common causes of community-acquired pneumonia include influenza A, influenza B, respiratory syncytial virus, human metapneumovirus, human parainfluenza viruses, adenovirus, human rhinovirus and other respiratory viruses; Streptococcus pneumoniae, Chlamydia pneumophila, and other pathogens that cause severe lower respiratory infections


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