Notes from the Field: Nosocomial Outbreak of Middle East Respiratory Syndrome in a Large Tertiary Care Hospital — Riyadh, Saudi Arabia, 2015

Abstract

Since the first diagnosis of Middle East respiratory syndrome (MERS) caused by the MERS coronavirus (MERS-CoV) in the Kingdom of Saudi Arabia in 2012, sporadic cases and clusters have occurred throughout the country (1). During June-August, 2015, a large MERS outbreak occurred at King Abulaziz Medical City, a 1,200-bed tertiary-care hospital that includes a 150-bed emergency department that registers 250,000 visits per year.In late June 2015, approximately 3 months after the last previously recognized MERS case in the hospital, a man aged 67 years with multiple comorbidities (diabetes, hypertension, congestive heart failure, and a history of coronary artery bypass graft surgery) and a 10-day history of fever and cough was evaluated in the emergency department ( Figure). The patient had no identified exposure to camels. A nasopharyngeal swab from the patient tested positive for MERS-CoV by reverse transcription-polymerase chain reaction (RT-PCR) (2). The patient was admitted and died in the hospital after 31 days. Although this patient's hospitalization overlapped with the onset of subsequent hospital-associated MERS cases, no direct links between this first case and any of the subsequent cases were identified.Approximately 3 weeks after the first patient's admission, a second patient, a man aged 56 years, with multiple comorbidities (diabetes with hypothyroidism, coronary artery disease, and hypertension with a history of coronary artery bypass surgery) and a history of camel exposure was evaluated in the emergency department for fever, cough, and shortness of breath. His nasopharyngeal specimen tested positive for MERS-CoV by RT-PCR. Three additional cases of MERS were epidemiologically linked to this patient's illness during his first week of hospitalization, including infections in two health care workers from the emergency department. An outbreak investigation was conducted by the hospital's infection control program to identify risk factors for infection and to develop and implement control measures. A suspected MERS case was defined as the occurrence of respiratory symptoms in a person with or without documented exposure to a patient with confirmed or probable MERS infection, but without confirmation by laboratory test results. A probable case was the occurrence of respiratory symptoms in a person with history of exposure to a patient with confirmed or probable MERS infection, but with inconclusive laboratory results (such as positive results by PCR on only one of the two genomic targets). A confirmed case was a suspected or probable case that was subsequently confirmed by a positive RT-PCR test for MERS-CoV. Contacts of persons with confirmed and probable cases were screened and persons with suspected cases were tested.A total of 130 MERS cases were detected at King Abulaziz Medical City during late June-late August. Among these cases, 81 (62%) were confirmed and 49 (38%) were probable, including 43 (33%) cases in health care workers; 20 of these 43 cases (47%) occurred in emergency department health care...

Vaccines against Middle East respiratory syndrome coronavirus for humans and camels

“…Although the most affected countries are rich, such as KSA, Qatar, and UAE, they might look into quicker measures to contain this virus even if those measures are more expensive than vaccines, which take long and laborious efforts. For example, a tertiary hospital in Riyadh, KSA, one of the biggest in the Middle East with 1200 beds and 250,000 visits to the ER per annum, with some VIP royal clinics, was hit by a MERS‐CoV outbreak in August 2015, resulting in 130 cases, with 40% mortality rate . The hospital responded by several actions regardless of the cost, among them closing down the hospital for weeks, building a separate ER for flulike symptoms with several negatively pressurized rooms, and constructing a car drive‐thru screening checkpoint at the entrance of the medical city to direct flulike patients to the new ER without any contact with them.…”

“…The hospital was then reopened and had to pay overtime to some staff to catch up with clinic schedules. These responses took only 7 weeks to complete and helped in clearing the MERS‐CoV from this large hospital in an astonishingly short time (personal communication with Dr. Bandar Al Knawy, CEO of King Abulaziz Medical City …”

“…Second, it requires quick actions, as the peak of the infection may not last for long, 2 weeks after the onset of MERS illness . Third, and most importantly, it requires identifying a large number of infected people with a high number of their contacts (n = 200–2000) who are willing to participate; however, clustered MERS‐CoV outbreaks are usually less than 255 cases, making it difficult to conduct a phase III efficacy trial during an outbreak.…”

Middle East respiratory syndrome coronavirus transmission among health care workers: Implication for infection control

“…[1][2][3][4][5][6] As of June 26, 2017, there have been 2,029 cases, including a total of 704 deaths, reported to the World Health Organization. [8][9][10][11][12] In addition, hemodialysis units were also highlighted as the focus of multiple documented and undocumented outbreaks in Al-Hasa and Taif, Saudi Arabia (SA). [8][9][10][11][12] In addition, hemodialysis units were also highlighted as the focus of multiple documented and undocumented outbreaks in Al-Hasa and Taif, Saudi Arabia (SA).…”

Closing the knowledge gaps on MERS: three and half years since its detection, what have we learnt and what needs to be done urgently?

“…From the public health perspective, the risk factors for nosocomial outbreaks are overcrowding, lack of proper assessment and triaging of suspected patients, uncontrolled patient movement, absence of patient cohorting and poor compliance with infection control practices by health-care workers (4,9). Evidence has also shown that early recognition of suspected case, appropriate triaging and isolation of suspected patient and rapid implementation of appropriate infection control measures were linked to interruption of transmission in hospitals (10).…”