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EDITORIAL
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 51-54

Middle-East respiratory syndrome-coronavirus: Putting emergency departments in the spotlight


1 Al-Imam Mohammed bin Saud Islamic University, Riyadh, Kingdom of Saudi Arabia
2 Department of Paediatrics, Prince Mohammed bin Abdulaziz Hospital, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
3 Department of Emergency, Prince Mohammed bin Abdulaziz Hospital, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
4 Department of Research, Prince Mohammed bin Abdulaziz Hospital, Ministry of Health, Riyadh, Kingdom of Saudi Arabia; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, USA

Date of Web Publication24-Apr-2017

Correspondence Address:
Ziad Ahmed Memish
Ministry of Health, Riyadh, Kingdom of Saudi Arabia, Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, USA

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DOI: 10.4103/jhs.JHS_23_17

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How to cite this article:
Ghazal HS, Ghazal S, Alharbi TM, Al Nujaidi M, Memish ZA. Middle-East respiratory syndrome-coronavirus: Putting emergency departments in the spotlight. J Health Spec 2017;5:51-4

How to cite this URL:
Ghazal HS, Ghazal S, Alharbi TM, Al Nujaidi M, Memish ZA. Middle-East respiratory syndrome-coronavirus: Putting emergency departments in the spotlight. J Health Spec [serial online] 2017 [cited 2017 Jul 23];5:51-4. Available from: http://www.thejhs.org/text.asp?2017/5/2/51/205073

Middle-East Respiratory Syndrome-Coronavirus (MERS-CoV) was first reported from the Kingdom of Saudi Arabia (KSA) in September 2012, caused by a novel betacoronavirus in lineage c (significantly different from severe acute respiratory syndrome [SARS]-CoV, which is also a betacoronavirus but in lineage b).[1] Since then more than 1,900 cases were reported globally out of which 1,550 cases were from KSA with an overall mortality of 40%.[2] This mortality rate is much higher than that of SARS – estimated at 15%, and is strongly age- and sex-dependent.[3] The disease had several patterns including sporadic community cases, small family clusters and large explosive nosocomial outbreaks in healthcare facilities (HCFs) with the emergency department (ED) being the key focus of disease entrance, transmission and spread.[4],[5],[6] Until effective vaccines and therapeutic agents are developed for this new emerging virus, the prevention and control of MERS-CoV transmission within medical facilities will only be possible by prompt detection, isolation and strict implementation of infection control measures.[7],[8] Without rapid point of care testing to diagnosis and identify MERS-CoV cases early; effective isolation and application of effective infection control practices will be practically impossible.

Spanning the 5 years since the virus was discovered, multiple large hospital outbreaks of MERS-CoV have been described in Jordan, KSA, United Arab Emirates (UAE) and South Korea.[9],[10],[11],[12],[13],[14],[15],[16],[17] Even before the official discovery of MERS-CoV from KSA in September 2012, the first ever reported cluster of MERS-CoV cases occurred in Zarqa, Jordan in March-April 2012 where 13 cases among healthcare workers (HCWs) were detected (intensivists and Intensive Care Unit [ICU] nurses) with two mortalities.[9] Post virus discovery in September 2012, the first large multi-hospital outbreak involved 4 HCFs in Alhassa region of KSA in April 2013 with a total of 23 confirmed cases (2 HCWs), and 11 probable cases were recorded.[10] This outbreak was focused in the haemodialysis unit, and the extensive investigation elucidated some of the critical information on the disease; including incubation period, clinical presentation, the complexity of the disease and its transmission modalities and the ease of outbreak control by application of simple infection control measures (contact and droplet precautions). In 2014, 2 simultaneous hospital outbreaks of MERS-CoV infection took place between February 17 and April 26 in Jeddah, KSA and Abu Dhabi, UAE; with a total of 128 MERS-CoV patients treated in 14 hospitals in KSA and 62 patients in UAE.[11],[12] The hub of the Jeddah large healthcare-associated cluster was in King Fahad Hospital (KFH) ED where overcrowding and bed occupancy of 578% for the 76 emergency beds, coupled with poor infection control practices, shared staff accommodation were the main reasons for the outbreak resulting in 78 cases at KFH (53 patients, 16 HCWs, 9 Visitors).[13] From September 2014–January 2015, the Western Region of Saudi Arabia was hit by another outbreak of 38 cases of MERS-CoV in 4 HCFs in Taif (13 HCWs) with the focus being the haemodialysis unit again; the mortality rate in this cluster was 55%.[14]

In 2015, the largest outbreak outside the Middle East took place in South Korea when a single infected Korean male traveller returning from the Middle East was able to infect 186 individuals in 86 HCFs, with 13 facilities exhibiting large nosocomial transmission.[15] In August, the same year, King Abdulaziz Medical City in Riyadh had to be closed off for over 2 months due to a large outbreak originating from its crowded state of the art ED resulting in a total of 130 confirmed cases.[16]

Expanding knowledge base on the disease and methods of transmission did not prevent the occurrence of another nosocomial cluster in King Khalid University hospital in Riyadh where a woman admitted through the acute ED on the 10th of June 2016, to the vascular surgery ward developed acute respiratory distress syndrome postoperatively that was caused by MERS-CoV; which was only diagnosed just before she passed away on the 22nd of June. The investigation revealed 24 contacts who tested positive for MERS including 18 HCWs and 3 household contacts. In addition, one case has been diagnosed in a household contact of a hospital patient who was diagnosed with the disease after exposure to the probable index.[17] All these healthcare-associated outbreaks have the following in common: lack of efficiency in identifying, triaging, isolating and limiting patients and HCWs contacts with symptomatic/asymptomatic MERS-CoV suspected cases. Immediate diagnoses and isolation of index cases, avoiding overcrowding healthcare environment, maintaining strict basic infection control practices and standards with strong infection control oversight is a must to avoid ED related HCFs outbreaks.

As part of the Ministry of Health (MoH) strategy to improve care for MERS-CoV cases Kingdom-wide, they assigned 4 tertiary state-of-the-art hospitals to be centres of excellence for MERS-CoV in late 2014. Prince Mohammed bin Abdulaziz Hospital (PMAH) is one of these facilities assigned to accommodate all confirmed cases of MERS-CoV infection in Riyadh area and centre for extracorporeal membrane oxygenation in the Central region. PMAH is a new MoH teaching, referral tertiary care hospital with 500 beds located in the eastern part of Riyadh city with a catchment area of 2,500,000 inhabitants. The challenges of preventing MERS-CoV transmission and spread in PMAH emergency room over 3 years (2014–2017) is described here.

When PMAH was assigned a centre of excellence for MERS-CoV, our knowledge about the disease and methods of transmission were scarce with no official policy to prevent disease transmission or spread in ED of hospitals. Our aim was to look critically at the measures applied at PMAH which were successful in preventing transmission of MERS-CoV in its busy ED. PMAH focused their efforts on: preventing crowding in any part of the hospital, allocating special areas in the hospital to triage as well as manage suspected and/or confirmed cases of MERS-CoV. In ED, a group of offices, close to main-ED were reconstructed and dedicated as respiratory zone-ED to receive all patients with respiratory symptoms. Special office, run by medical staff (Eye-ball) and located in the entry of main-ED, was initiated where assigned medical staff asked every patient if he/she: has any respiratory symptoms, fever, history of contact with MERS-CoV patients or visiting ED of any healthcare facilities within the past 2 weeks. If any of the answers was positive; patients would be directed to the respiratory zone-ED (R-ED), otherwise will be seen in the main-ED. Before sending the patient to R-ED he/she would be asked along with his/her attendants to wear surgical mask with the help of the nurse.

The R-ED area is classified into two waiting rooms with chairs 1.5 m apart, registration office with a door separating waiting room from the rest of the R-ED. Inside the examination area, there is one examination room, one procedure room, one X-ray room, one pharmacy, two negative pressure isolation rooms, utility rooms, small store and lounge. In every room and corridor, there are portable High-Efficiency Particulate Air filters [Figure 1].
Figure 1: Patients triage in emergency department

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All staff working in the ED got special training in wearing personal protective equipments (PPEs) and isolation precautions as well as other infection control measures. Annual fit testing of all staff in the ED was done and was routinely monitored with dedicated staff assigned to the respiratory zone. One infection control nurse is always in the area to guide and monitor staff. The area as well, is visited twice daily by medical administration. Staff must wear surgical mask in the corridor and change into N95 mask, isolation gown and non-sterile gloves in the examination room, procedure room or isolation rooms. If there is a HCW with significant unprotected exposure to a MERS-CoV confirmed case, an investigation will be initiated [Figure 2]. All surfaces are wiped frequently with hydrogen peroxide, and any room will be fumigated with hydrogen peroxide if one of the patients proved to be positive for MERS-CoV or got resuscitated in the area. Special lift with special access is dedicated to transfer MERS-CoV suspected or confirmed patients to the fourth floor which is the inpatient isolation area with 36 beds assigned for MERS-CoV inpatients, and 16 beds in the isolation ICU. Referred MERS-CoV confirmed patients to our hospital are admitted directly to the MERS-CoV dedicated isolation ward without stopping in the ED. From January 2015 till the end of December 2016, a total of 47,059 patients were examined in the respiratory zone of the ED. Swabs for MERS-CoV were done for 4,748 patients with 100 MERS-CoV patients confirmed positive by real-time PCR. Hence, the positivity was 8%. None of the HCWs or patients in either medical ED or R-ED were infected [Table 1].
Figure 2: Algorithm for management of staff with unprotected exposure

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Table 1: Census for respiratory patients at Prince Mohammed bin Abdulaziz Hospital 2014-2016

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There is no doubt that MERS-CoV remains a significant public health threat and has put a major strain on the public health infrastructure in the Arabian Peninsula with significant economic impact. Unfortunately, these challenges will continue as we struggle to fill the gaps in our knowledge regarding the virus, its sources, transmission routes, how to identify MERS-CoV cases among patients presenting to HCFs with influenza-like illness (ILI), how common is asymptomatic MERS-CoV and can they infect others, and finally identify effective therapeutic agents and preventative vaccine.

Multiple studies from KSA have demonstrated the challenges faced by ED staff in identifying MERS-CoV patients among the thousands of patients presenting with ILI.[19],[20] There is no currently reliable clinical, laboratory or radiological findings that can identify MERS-CoV-associated ILI from other viruses. Fortunately, there are new reports emerging from Europe and China on the availability of new point of care testing that would assist healthcare providers in the ED to identify patients with MERS-CoV within 60 min of presentation, with a high level of sensitivity and specificity.[18],[21] This will allow the ED staff in hospitals Kingdom-wide to effectively and efficiently identify, promptly triage, isolate and track a surge of potentially infectious patients presenting to their EDs during the MERS-CoV peak seasons.

Creating separate respiratory zone in the ED with strong application of infection control measures and frequent monitoring may reduce MERS-CoV transmission and generation of HCFs outbreaks. Continuous sharing of experiences and knowledge among facilities in KSA caring for MERS-CoV patients with the global public health community about the value and effectiveness of each infection control intervention will provide answers and eventually lead to evidence-based guidelines and standards that will promote safety in HCFs both for patients and HCWs.

 
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