Global & Disaster Medicine

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Thirteen of the newly reported Saudi cases are linked to a hospital MERS-CoV outbreak

WHO

Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia

Disease outbreak news
17 August 2017

Between 4 July and 12 August 2017, the national IHR Focal Point of Saudi Arabia reported 26 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection including six deaths, and two deaths among previously reported cases.

Details of the cases

Detailed information concerning the cases reported can be found in a separate document (see link below).

Among the 26 newly reported cases, 13 are associated with a cluster in a hospital in Al Jawf Region, Saudi Arabia. The initial case was a 51-year-old reported on 2 August 2017. To date, 12 cases have been identified through contact tracing. These cases include eight health care workers (all asymptomatic) in the hospital where the initial case was treated, one hospital contact (a 70-year-old male) and three household contacts. Follow up of health care workers, hospital and household contacts are ongoing.

Globally, 2066 laboratory-confirmed cases of infection with MERS-CoV including at least 720 related deaths have been reported to WHO.

Public health response

The Ministry of Health of Saudi Arabia evaluates each case and their contacts and implements measures to limit further human-to-human transmission and bring Middle East Respiratory Syndrome (MERS) outbreaks under control. The measures taken by Ministry of Health officials in Saudi Arabia include:

  • Risk stratification and active tracing for contacts in healthcare and in communities. High risk contacts (e.g. unprotected exposure to a case or engagement in an aerosol generating procedure) are tested by PCR regardless of having symptoms. Health care workers are exempted from work until they are cleared by infection control experts.
  • Trained hospital epidemiologists have been deployed to sites within 24 hours of identifying an outbreak.
  • Enforcement of strict adherence to environmental disinfection and terminal cleaning of affected areas.
  • Enforcement of visual triage for respiratory diseases in emergency department and outpatient departments and ensuring the 24/7 availability of trained nurses for early detection of patients with respiratory symptoms, and proper documentation on triage forms.
  • Extensive training of all health care workers on case definition for early detection, implementation of isolation precautions, proper selection, donning and doffing of personal protective equipment (PPE), hand hygiene and environmental cleaning and disinfection.
  • Ensuring availability of infection prevention supplies including hand sanitizer, PPEs, surface disinfectants, portable HEPA filters and fumigation machines.
  • Ensuring that all health care workers are fit tested for high efficiency respirators.
  • Implementing the policy of not allowing health care personnel working in a facility affected by an outbreak to travel or work in Hajj premises or in any healthcare facility until they are medical cleared.

WHO risk assessment

MERS-CoV causes severe human infections resulting in high mortality and has demonstrated the ability to transmit between humans. So far, the observed non-sustained human-to-human transmission has occurred mainly in health care settings.

The notification of additional cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East, and that cases will continue to be exported to other countries by individuals who might acquire the infection after exposure to animals or animal products (for example, following contact with dromedaries) or human source (for example, in a health care setting). WHO continues to monitor the epidemiological situation and conducts risk assessment based on the latest available information.

WHO advice

Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for acute respiratory infections and to carefully review any unusual patterns.

Infection prevention and control measures are critical to prevent the possible spread of MERS-CoV in health care facilities. It is not always possible to identify patients with MERS-CoV early because like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Therefore, health-care workers should always apply standard precautions consistently with all patients, regardless of their diagnosis. Droplet precautions should be added to the standard precautions when providing care to patients with symptoms of acute respiratory infection; contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection; airborne precautions should be applied when performing aerosol generating procedures.

Until more is understood about MERS-CoV, people with diabetes, renal failure, chronic lung disease, and immunocompromised persons are considered to be at high risk of severe disease from MERS-CoV infection. Therefore, in addition to avoiding close contact with suspected or confirmed human cases of the disease, people with these conditions should avoid close contact with animals, particularly camels, when visiting farms, markets, or barn areas where the virus is known to be potentially circulating. General hygiene measures, such as regular hand washing before and after touching animals and avoiding contact with sick animals, should be adhered to.

Food hygiene practices should be observed. People should avoid drinking raw camel milk or camel urine, or eating meat that has not been properly cooked.

WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.


Saudi MOH: ‘1 New Confirmed Corona Cases Recorded’

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Saudi MOH: ‘1 New Confirmed Corona Cases Recorded’

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WHO: Early MERS-CoV identification in the community and in healthcare facilities and compliance with infection prevention and control protocols still pose major challenges

WHO

“Between 2012 and 21 July 2017, 2040 laboratory-confirmed cases of Middle East respiratory syndrome-coronavirus (MERS-CoV) infection were reported to WHO, 82% of whom were reported by the Kingdom of Saudi Arabi. In total, cases have been reported from 27 countries in the Middle East, North Africa, Europe, the United States of America, and Asia. Males above the age of 60 with underlying conditions, such as diabetes, hypertension and renal failure, are at a higher risk of severe disease, including death. To date, at least 710 individuals have died (crude CFR 34.8%)…….Since the last global update of 5 December 2016, approximately 31% of cases reported to WHO were associated with transmission in a health-care facility. These cases included health-care workers (40 cases), patients sharing rooms/wards with MERS patients, or family visitor……..”

Summary:  “….Summary – information available from 2012 to date
Thus far, no sustained human-to-human transmission has occurred anywhere in the world, however limited nonsustained human-to-human transmission in health-care facilities remains a prominent feature of this virus. WHO continues to work with health authorities in the affected countries. WHO understands that health authorities in affected countries, especially those in the most affected countries, are aggressively investigating cases and contacts, including testing for MERS-CoV among asymptomatic contacts, and applying mitigation measures to stop humanto-human transmission in health-care settings.
Of all laboratory-confirmed cases reported to date (n=2040), the median age is 52 (IQR 36-65; range >1-109 years old) and 66.4% are male.
At the time of reporting, 21.5% of the 2040 cases were reported to have no or mild symptoms, while 46.8% had severe disease or died. Overall, 19.6% of the cases reported to date have been in health-care workers.
Since 2012, 27 countries have reported cases of MERS-CoV infection. In the Middle East: Bahrain, Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, the Kingdom of Saudi Arabia, the United Arab Emirates and Yemen; in Africa: Algeria and Tunisia; in Europe: Austria, France, Germany, Greece, Italy, the Netherlands, Turkey and the United Kingdom; in Asia: China, the Republic of Korea, Malaysia, the Philippines and Thailand; and in the Americas: the United States of America (Table 1).
The majority of cases (approximately 82%) have been reported from Saudi Arabia (Figure 1).
Populations in close contact with dromedaries (e.g. farmers, abattoir workers, shepherds, dromedary owners) and healthcare workers caring for MERS-CoV patients are believed to be at higher risk of infection. Healthy adults tend to have mild subclinical or asymptomatic infections. To date, limited human-to-human transmission has occurred between close contacts of confirmed cases in household settings. More efficient human-to-human transmission occurs in health-care settings due to inadequate and/or incomplete compliance with the infection prevention and control measures and delay in triage or isolation of suspected MERS patients. Health-care-associated transmission has been documented in several countries between 2012-2016, including the Kingdom of Saudi Arabia, Jordan, the United Arab Emirates, France, the United Kingdom, and the Republic of Korea with varying outbreak sizes (2-180 reported cases per outbreak). The largest outbreak outside of the Middle East occurred in the Republic of Korea resulting in 186 cases (including one case who travelled to China) and 38 deaths.

Overall, the reproduction number (R0) of MERS-CoV is <1 with significant heterogeneity in specific contexts. Specifically, outbreaks in health-care settings can have R>1,
but they can be brought under control (R<1) with proper application of infection prevention and control measures and early isolation of subsequent cases. ….”


Diagnostic Delays in 537 Symptomatic Cases of MERS-CoV Infection in Saudi Arabia

International Journal of Infectious Diseases

Abstract

Background

Although the literature indicates the potential outcomes of a patient’s delay in seeking medical support is associated with poor clinical outcomes, delays in the diagnosis itself remain poorly understood in patients with Middle East Respiratory Syndrome − Coronavirus (MERS-CoV). This study aims to estimate the median time interval of confirmed diagnosis after symptom onset and identify its potential predictors in Saudi Arabian MERS patients.

Methods

A retrospective study involved patients confirmed with MERS who were publicly reported by the World Health Organization (WHO).

Results

537 symptomatic cases of MERS-CoV infection were included. The median time between symptom onset and confirming MERS diagnosis was 4 days (IQR: 2-7), ranging from 0 to 36 days. According to a negative binomial model, the unadjusted rate ratio (RR) of delays in the diagnosis was significantly higher in older patients (> 65 years) (RR = 1.42), non-healthcare workers (RR = 1.74), patients with severity of illness (RR = 1.22), those with unknown sources of infections (RR = 1.84), and those who were in close contact with camels (RR = 1.74). After accounting for confounders, the adjusted rate ratio (aRR) of delays in the diagnosis was independently associated with unknown sources of infections (aRR = 1.68) and those in close contact with camels (aRR = 1.58).

Conclusion

The time interval from onset until diagnosis was greater in older patients, non-healthcare workers, patients with severity of illness, patients with unknown sources of infections, and patients in close contact with camels. The findings warrant educational intervention to raise the general public awareness on the importance of early-symptom notification.


Saudi MOH: ‘1 New Confirmed Corona Case Recorded’

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Lebanon’s ministry of public health reported a MERS-CoV infection in a man who had recently traveled to Saudi Arabia.

Lebanon Public Health

Map of Lebanon


WHO: Between 1 and 10 June 2017, the national IHR focal point of Saudi Arabia reported 35 additional cases of MERS-CoV

WHO

Disease outbreak news
13 June 2017

Between 1 and 10 June 2017, the national IHR focal point of Saudi Arabia reported 35 additional cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection including three fatal cases and one death among previously reported cases (case number 5 in the Disease Outbreak News published on 6 June 2017).

Details of the cases

Detailed information concerning the cases reported can be found in a separate document (see link below).

Thirty-two of the 35 newly reported cases are associated with three simultaneous clusters of MERS, of which two are related. A description of the three clusters is below.

Cluster 1

A cluster of MERS has been identified in a hospital in Riyadh city, Riyadh Region. Twenty three cases associated with this cluster thus far and include the first identified case (a 47-year-old male reported on 1 June), 14 asymptomatic health care worker contacts, one household contact, and seven hospital contacts who were patients.

Cluster 2

This MERS cluster is occurring in a second hospital in Riyadh City, Riyadh Region. This cluster is related to cluster 1 above. The first identified case of this second cluster visited the emergency room of the cluster 1 hospital. He was asymptomatic and following this visit in hospital 1, he continued to receive kidney dialysis sessions in the second hospital. To date, this cluster involves six cases, including the case involved in cluster 1, and secondary household and health care worker contacts.

Cluster 3

This MERS cluster is currently occurring in a third hospital in Riyadh city, Riyadh Region. To date the cluster involves the four cases including the first identified case who reported contacts with dromedary camels and three asymptomatic or mild cases who were health care worker contacts.

Public health response

The Ministry of Health of Saudi Arabia is evaluating each case and their contacts and implementing measures to limit further human-to-human transmission and bring these outbreaks to a control. These measures include:

  • Proper isolation for all confirmed cases;
  • Active tracing for all contacts of patients, healthcare workers and community contacts;
  • Identification of high and low risk contacts with daily monitoring for all during incubation period of the 14 days and performing laboratory testing for high risk contacts, regardless of the development of symptoms;
  • Regular updating of the line list of cases and contacts and conducting epidemiological analysis of data to identify the source of infection, links between patients and reasons for human-to-human transmission within hospitals;
  • Searching for suspected cases between patients and healthcare workers based on case definition of the disease;
  • Enforcement of strict adherence to proper environmental cleaning, disinfection and terminal cleaning and disinfection for hospital environment with special care in departments where the outbreaks are currently occurring or have occurred;
  • Enforcement of visual triage for respiratory diseases in emergency department and outpatient departments and ensure the 24/7 availability of a trained nurse for early detection of patients with respiratory symptoms, and proper documentation in triage forms;
  • Extensive training of all healthcare workers on case definition for early detection, implementation of isolation precautions, proper selection, donning and doffing of PPEs, hand hygiene and environmental cleaning and disinfection;
  • Ensuring that all healthcare workers tested for N95 fitting (fit test);
  • Ensuring availability of infection prevention supplies including hand sanitizer, PPEs, surface disinfectants, portable HEPA filters and fumigation machines;
  • Enforcing the implementation of a policy of not allowing healthcare workers to travel without medical clearance to prevent the spread of the virus to other countries.

For cases that report contact with dromedary camels, investigations of MERS-CoV infection in dromedaries is conducted by Ministry of Agriculture officials.

Globally, 2015 laboratory-confirmed cases of infection with MERS-CoV including at least 703 related deaths have been reported to WHO since 2012.

WHO risk assessment

MERS-CoV causes severe human infections resulting in high mortality and has demonstrated the ability to transmit between humans. So far, the observed human-to-human transmission has occurred mainly in health care settings.

The notification of additional cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East, and that cases will continue to be exported to other countries by individuals who might acquire the infection after exposure to animals or animal products (for example, following contact with dromedaries) or human source (for example, in a health care setting). WHO is working closely with the Ministry of Health in Saudi Arabia, continues to monitor the epidemiological situation and viral changes, and conducts risk assessment based on the latest available information. To date, there is no indication that there is sustained human-to-human transmission or that the epidemiologic pattern or viral characteristics are different than what has been reported previously.

WHO advice

Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for acute respiratory infections and to carefully review any unusual patterns.

Infection prevention and control measures are critical to prevent the possible spread of MERS-CoV in health care facilities. It is not always possible to identify patients with MERS-CoV early because like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Therefore, health-care workers should always apply standard precautions consistently with all patients, regardless of their diagnosis. Droplet precautions should be added to the standard precautions when providing care to patients with symptoms of acute respiratory infection; contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection; airborne precautions should be applied when performing aerosol generating procedures.

Until more is understood about MERS-CoV, people with diabetes, renal failure, chronic lung disease, and immunocompromised persons are considered to be at high risk of severe disease from MERS-CoV infection. Therefore, these people should avoid close contact with animals, particularly camels, when visiting farms, markets, or barn areas where the virus is known to be potentially circulating. General hygiene measures, such as regular hand washing before and after touching animals and avoiding contact with sick animals, should be adhered to.

Food hygiene practices should be observed. People should avoid drinking raw camel milk or camel urine, or eating meat that has not been properly cooked.

WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.


The Saudi Arabian Ministry of Health (MOH) reported 7 new cases of MERS-CoV, all associated with hospital outbreaks

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“……five healthcare workers from Riyadh were diagnosed as having MERS-CoV. The three women and two men are all expatriate healthcare workers who contracted the disease on the job. Their ages range from 35 to 57, and all are in stable condition. Only two of the five employees had symptoms…..”


MERS-CoV – Saudi Arabia, United Arab Emirates, and Qatar

CDC

Disease outbreak news
6 June 2017

Between 21 April and 29 May 2017, the National IHR Focal Point of Saudi Arabia reported 25 additional cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection including six fatal cases. On 16 May 2017, the IHR NFP of the United Arab Emirates reported two (2) additional case of MERS-CoV. On 23 May 2017, the National IHR Focal Point of Qatar reported one additional case of MERS-CoV.

Details of the cases

Detailed information concerning the cases reported can be found in a separate document (see link below).

Saudi Arabia

Between 21 April and 29 May 2017, 25 cases of MERS-CoV infection were reported in Saudi Arabia including six fatal cases. Twelve of the 25 reported cases during this time period were associated with three simultaneous, yet unrelated clusters of MERS cases. The Ministry of Health is evaluating each case and their contacts and implementing measures to limit further human-to-human transmission. A description of the three clusters is below.

Cluster 1

A cluster of cases has been identified at a hospital in Bisha city, Assir Region. Cases associated with this cluster are:

  • First identified fatal case: A 71-year-old male reported on 9 May.
  • Secondary case – Healthcare contact: A 54-year-old male reported to WHO on 13 May.
  • Secondary case – Healthcare contact: A 57-year-old male reported to WHO on 17 May.
Cluster 2

A cluster of cases has been identified in a hospital in Riyadh city, Riyadh Region. Cases associated with this cluster are:

  • First identified fatal case: A 55-year-old male reported to WHO on 14 May.
  • Secondary case – Healthcare contact: A 33-year-old male reported to WHO on 15 May.
  • Secondary case – Healthcare contact: A 30-year-old female reported to WHO on 15 May.
  • Secondary case – Healthcare contact: A 25-year-old female reported to WHO on 16 May.
  • Secondary case – Healthcare contact: A 38-year-old male reported to WHO on 17 May.
Cluster 3

A third cluster was detected at a hospital in Wadi Aldwaser city, Riyadh Region. This outbreak is believed to be over based on the follow-up period of all contacts. The four newly identified cases associated with this outbreak are listed below. In total, five cases were associated with this outbreak: First identified case: A 55-year-old male previously reported to WHO on 19 April (see Disease Outbreak News published on 27 April 2017).

  • Secondary case – Household contact: A 50-year-old male reported to WHO on 21 April.
  • Secondary case – Household contact: A 58-year-old male reported to WHO on 21 April.
  • Secondary case – Healthcare contact: A 31-year-old male reported to WHO on 21 April.
  • Secondary case – Household contact: A 26-year-old male reported to WHO on 26 April.

United Arab Emirates

On 16 May 2017, two cases of MERS-CoV infection were reported in the United Arab Emirates. Both cases were reported from Al Ain city and both have reported direct links to dromedary camels. The first case that was identified, a 69-year-old male farmer, is in critical condition in hospital and the second case, a 45-year-old male butcher, is asymptomatic and identified during contact tracing of the first case. Contact tracing and dromedary investigations are ongoing.

Qatar

On 23 May 2017, one case of MERS-CoV infection was reported in Qatar. The case, a 29 year old male from Doha has reported frequent contact with dromedary camels. The Department of Health Protection and Communicable Disease Control in the Ministry of Public Health and animal health resources are currently carrying out case investigation and contact tracing.

Globally, since September 2012, WHO has been notified of 1980 laboratory-confirmed cases of infection with MERS-CoV including at least 699 related deaths have been reported.

WHO risk assessment

MERS-CoV causes severe human infections resulting in high mortality and has demonstrated the ability to transmit between humans. So far, the observed human-to-human transmission has occurred mainly in health care settings.

The notification of additional cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East, and that cases will continue to be exported to other countries by individuals who might acquire the infection after exposure to animals or animal products (for example, following contact with dromedaries) or human source (for example, in a health care setting). WHO continues to monitor the epidemiological situation and conducts risk assessment based on the latest available information.

WHO advice

Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for acute respiratory infections and to carefully review any unusual patterns.

Infection prevention and control measures are critical to prevent the possible spread of MERS-CoV in health care facilities. It is not always possible to identify patients with MERS-CoV early because like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Therefore, health-care workers should always apply standard precautions consistently with all patients, regardless of their diagnosis. Droplet precautions should be added to the standard precautions when providing care to patients with symptoms of acute respiratory infection; contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection; airborne precautions should be applied when performing aerosol generating procedures.

Until more is understood about MERS-CoV, people with diabetes, renal failure, chronic lung disease, and immunocompromised persons are considered to be at high risk of severe disease from MERS-CoV infection. Therefore, these people should avoid close contact with animals, particularly dromedary camels, when visiting farms, markets, or barn areas where the virus is known to be potentially circulating. General hygiene measures, such as regular hand washing before and after touching animals and avoiding contact with sick animals, should be adhered to.

Food hygiene practices should be observed. People should avoid drinking raw camel milk or camel urine, or eating meat that has not been properly cooked.

WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.


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