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Published Date: 2016-02-20 04:58:27
Subject: PRO/AH/EDR> MERS-CoV (23): Saudi Arabia (RI) 2015 outbreak, RFI
Archive Number: 20160220.4036190

MERS-COV (23): SAUDI ARABIA (RIYADH) 2015 OUTBREAK, REQUEST FOR INFORMATION
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A ProMED-mail post
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International Society for Infectious Diseases
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In this update:
[1] Saudi Arabia, 1 newly confirmed asymptomatic case
[2] Saudi Arabia, 2015 nosocomial outbreak - Riyadh

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[1] Saudi Arabia, 1 newly confirmed asymptomatic case
Date: Fri 19 Feb 2016
Source: Saudi Arabia Ministry of Health [edited]
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/default.aspx?PageIndex=1

According to the Saudi MOH website there have been:
1298 laboratory-confirmed cases of MERS-CoV infection including
554 fatalities,
741 recoveries, and
3 currently active cases [1 asymptomatic].

In the past 24 hours there has been 1 newly confirmed case and 1 newly reported recovery:

Newly confirmed case: a 28 year old female expat health care worker from Al-kharj, who is asymptomatic, and was a contact of a previously confirmed case.

Newly reported recovery: an 85 year old Saudi male, non-health care worker from Almuthnab, with a history of pre-existing co-morbidities, and who had been reported as a confirmed case on 22 Jan 2016 as a primary case in a stable condition with a history of contact with camels.

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[It appears as though there is an increase in MERS-CoV activity in Al-kharj in Riyadh province. Since 27 Jan 2016 there have been 5 newly confirmed cases, of whom 2 were fatal, and 1 (the most recent confirmation) was a currently asymptomatic infected health care worker who cared for one of the other known laboratory-confirmed cases.

Of the 5 cases in Al-kharj, 2 were reported to have contact with camels, 1 was a household contact of an individual with contact with camels, 1 was a health care worker (HCW) with contact with other case(s), and the 5th is currently under investigation for possible sources of exposures to the MERS-CoV.

In addition to these 5 cases reported from Al-karhj, since the beginning of February 2016 there have been 3 additional cases reported from Riyadh, none of whom were reported to have had contact with camels. One can't help but wonder if these additional cases reported from Riyadh may be related to the cluster of cases being reported from Al-kharj, remembering that Al-kharj is approximately 77 km [about 48 miles] from Riyadh.

More information on this apparent cluster of cases in Al-kharj would be greatly appreciated.

A map showing the locations of the cases can be found at the source URL, and the HealthMap/ProMED map of Saudi Arabia can be found at http://healthmap.org/promed/p/131. - Mod.MPP]

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[2] Saudi Arabia, 2015 nosocomial outbreak - Riyadh
Date: Fri 19 Feb 2016
Source: CDC. MMWR Morb Mortal Wkly Rep 19 Feb 2016; 65(6):163-164 [edited]
http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a5.htm?s_cid=mm6506a5_e

Notes from the field: nosocomial outbreak of Middle East respiratory syndrome in a large tertiary care hospital -- Riyadh, Saudi Arabia, 2015
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Authors: Balkhy HH, Alenazi TH, Alshamrani MM, Baffoe-Bonnie H, Al-Abdely HM, El-Saed A, et al.

Since the 1st 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 [Abdulaziz] Medical City, a 1200-bed tertiary care hospital which 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 at source URL: number of cases of Middle East respiratory syndrome (N=130), by week of symptom onset and health care worker (HCW) status -- King Abdulaziz Medical City, Riyadh, Saudi Arabia, June-August, 2015. Bar chart shows the number of cases of Middle East respiratory syndrome (N=130), by week of symptom onset and health care worker status in King Abdulaziz Medical City, Riyadh, Saudi Arabia, during June-August, 2015.] 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 1st case and any of the subsequent cases were identified.

About 3 weeks after the 1st patient's admission, a 2nd 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 1st week of hospitalization, including infections in 2 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 2 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 to late August [2015]. Among these cases, 81 (62 per cent) were confirmed and 49 (38 per cent) were probable, including 43 (33 per cent) cases in health care workers; 20 of these 43 cases (47 per cent) occurred in emergency department health care workers, and 23 (53 per cent) were in health care workers from other areas of the hospital. The majority of confirmed cases were linked to the emergency department. The median age of MERS patients who were health care workers was 37 years, and 77 per cent were female; among MERS patients who were not health care workers, the median age was 66 years, and 65 per cent were male. Signs and symptoms included fever and one or more respiratory symptoms, primarily cough and shortness of breath. Twenty-one (16 per cent) asymptomatic cases were detected during contact screening, including infection in 18 health care workers. Overall, 96 (74 per cent) MERS patients required hospitalization, including 63 (66 per cent) who required intensive care management; 34 (26 per cent) patients were isolated at home. Among all 130 cases, 51 (53 per cent) died; no deaths occurred among health care workers.

On [2 Aug 2015], a preexisting Infectious Disease Epidemic Plan (IDEP), established by the hospital outbreak committee and based on CDC and World Health Organization guidelines (3,4), was activated ([figure at source URL]). The plan included strict enforcement of infection control measures, including hand hygiene, airborne and contact isolation for confirmed and probable cases, and droplet and contact isolation for suspected cases. Measures were taken to house suspected patients and confirmed/probable patients on separate wards. Because cases continued to be identified despite the hospital's status of being in level II IDEP, on [18 Aug 2015], the plan was escalated to the highest level, IDEP level III, which included closure of the emergency department, postponement of elective surgical procedures, and suspension of all outpatient appointments and visits. Complete evacuation of the emergency department was achieved on [22 Aug 2015], and was associated with a rapid decline in the number of new cases. Onset of symptoms in the last infected patient was [28 Aug 2015]. On [28 Sep 2015], the end of outbreak was declared after the completion of two 14-day incubation periods without further identification of new cases.

This large MERS outbreak in a major tertiary care hospital in Riyadh was thought to be related to emergency department overcrowding, uncontrolled patient movement, and high visitor traffic. The outbreak required institution of multiple measures to interrupt transmission, including almost complete shutdown of the hospital. Primary MERS cases have been linked to patients with camel exposure in previously described outbreaks (5) and exposure to camels was confirmed in 3 patients during the early stages of this outbreak. Escalation of the outbreak, however, was clearly linked to extended health care-related person-to-person transmission. In addition to the community transmission, 4 generations of hospital transmission were believed to have occurred during the outbreak. Although data are still limited, this occurrence is considered a more intense transmission than has been previously described in similar outbreaks (6). Although the outbreak was associated with considerable patient mortality, no deaths occurred among health care workers, who were younger, healthier, and had fewer comorbidities compared with patients who were not health care workers. Early recognition of cases and rapid implementation of infection control guidance is necessary to prevent health care facility-associated outbreaks of MERS-CoV.

References
1. Alameer K, Abukhzam B, Khan W, El-Saed A, Balkhy H. Middle East respiratory syndrome coronavirus (MERS-Cov) screening of exposed healthcare workers in a tertiary care hospital in Saudi Arabia. Antimicrob Resist Infect Control 2015;4(Suppl 1):O57.
2. WHO. Laboratory testing for Middle East respiratory syndrome coronavirus. Interim guidance. Geneva, Switzerland: World Health Organization; 2015. http://apps.who.int/iris/bitstream/10665/176982/1/WHO_MERS_LAB_15.1_eng.pdf?ua=1
3. CDC. Interim infection prevention and control recommendations for hospitalized patients with Middle East respiratory syndrome coronavirus (MERS-CoV). Atlanta, GA: US Department of Health and Human Services, CDC; 2015. http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html#infection-prevention
4. WHO. Infection prevention and control of epidemic-and pandemic-prone acute respiratory diseases in health care. Geneva, Switzerland: World Health Organization, 2007. http://apps.who.int/iris/bitstream/10665/69707/1/WHO_CDS_EPR_2007.6_eng.pdf?ua=1
5. Alraddadi BM, Watson JT, Almarashi A, et al. Risk factors for primary Middle East respiratory syndrome coronavirus illness in humans, Saudi Arabia, 2014. Emerg Infect Dis 2016;22:49-55. http://wwwnc.cdc.gov/eid/article/22/1/15-1340_article
6. Fagbo SF, Skakni L, Chu DKW, et al. Molecular epidemiology of hospital outbreak of Middle East respiratory syndrome, Riyadh, Saudi Arabia, 2014. Emerg Infect Dis 2015;21:1981-8. http://wwwnc.cdc.gov/eid/article/21/11/15-0944_article.

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[In reading the above report, there appear to be similarities with the situation reported in the MERS-CoV outbreak in South Korea during the period May-early July 2015 -- with transmission "related to emergency department overcrowding, uncontrolled patient movement, and high visitor traffic". Closure of the emergency department seemed to be important to interrupt transmission of the MERS-CoV in the above outbreak as well as in the outbreak in South Korea. Interestingly as well, the above outbreak was associated with 4 generations of transmission of the MERS-CoV, also seen in the outbreak in South Korea suggesting there have not been significant changes in transmission patterns and the epidemiology of the disease. Noteworthy is the very high case fatality rate observed among non-health care workers -- although 21 of the cases were asymptomatic, identified during contact screening, of whom 18 were in health care workers, thereby "stacking the deck" (denominator of numbers of cases) with mild cases. More information on the risk factors for mortality in this outbreak would be greatly appreciated. - Mod.MPP]

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