Identified Transmission Dynamics of Middle East Respiratory Syndrome Coronavirus Infection During an Outbreak: Implications of an Overcrowded Emergency Department

Alenazi, Thamer H.; Arbash, Hussain A. Al; El-Saed, Aiman; Alshamrani, Majid M.; Baffoe-Bonnie, Henry; Arabi, Yaseen M.; Johani, Sameera M. Al; Hijazi, Ra’ed; Alothman, Adel; Balkhy, Hanan H.

doi:10.1093/cid/cix352

Cited by 36 publications

(25 citation statements)

References 17 publications

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“…Our molecular and epidemiologic investigation demonstrated separate virus introductions at the 2 facilities, each by a single index case. Similar to previous outbreaks, 3,21,22 transmission was characterized by early superspreading events, which led to a rapidly escalating number of cases.…”

Section: Discussionmentioning

confidence: 54%

Scope and extent of healthcare-associated Middle East respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in Riyadh, Saudi Arabia, 2017

Alanazi

Killerby

Biggs

et al. 2018

Infect. Control Hosp. Epidemiol.

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Objective: To investigate a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak event involving multiple healthcare facilities in Riyadh, Saudi Arabia; to characterize transmission; and to explore infection control implications. Design: Outbreak investigation. Setting: Cases presented in 4 healthcare facilities in Riyadh, Saudi Arabia: a tertiary-care hospital, a specialty pulmonary hospital, an outpatient clinic, and an outpatient dialysis unit. Methods: Contact tracing and testing were performed following reports of cases at 2 hospitals. Laboratory results were confirmed by realtime reverse transcription polymerase chain reaction (rRT-PCR) and/or genome sequencing. We assessed exposures and determined seropositivity among available healthcare personnel (HCP) cases and HCP contacts of cases. Results: In total, 48 cases were identified, involving patients, HCP, and family members across 2 hospitals, an outpatient clinic, and a dialysis clinic. At each hospital, transmission was linked to a unique index case. Moreover, 4 cases were associated with superspreading events (any interaction where a case patient transmitted to ≥5 subsequent case patients). All 4 of these patients were severely ill, were initially not recognized as MERS-CoV cases, and subsequently died. Genomic sequences clustered separately, suggesting 2 distinct outbreaks. Overall, 4 (24%) of 17 HCP cases and 3 (3%) of 114 HCP contacts of cases were seropositive. Conclusions: We describe 2 distinct healthcare-associated outbreaks, each initiated by a unique index case and characterized by multiple superspreading events. Delays in recognition and in subsequent implementation of control measures contributed to secondary transmission. Prompt contact tracing, repeated testing, HCP furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission.Middle East respiratory syndrome coronavirus (MERS-CoV) is a novel β-coronavirus identified in 2012. 1 Infection may result in upper or lower respiratory tract illness, with symptoms ranging from inapparent or mild to rapidly progressive respiratory failure and, iñ 35% of confirmed cases, death. 2 Numerous large, healthcareassociated outbreaks of MERS-CoV have occurred, resulting in transmission to patients, visitors, and healthcare personnel (HCP). [3][4][5][6] Prevention of MERS-CoV transmission in healthcare settings requires effective triaging and a high clinical index of suspicion to Cite this article: Alanazi KH, et al. (2019). Scope and extent of healthcare-associated Middle East respiratory syndrome coronavirus transmission during two

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Section: Discussionmentioning

confidence: 54%

Scope and extent of healthcare-associated Middle East respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in Riyadh, Saudi Arabia, 2017

Alanazi

Killerby

Biggs

et al. 2018

Infect. Control Hosp. Epidemiol.

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“…76 Nosocomial transmission is often due to a delayed diagnosis of MERS-CoV infection in a patient shedding MERS-CoV in a crowded health-care setting, such as an inpatient ward, emergency department, or renal dialysis unit. [28][29][30][31]36,[47][48][49]52,56 Early recognition of MERS-CoV infections, improved compliance with internationally recommended infection control protocols, and rapid implementation of infection control measures are required to prevent outbreaks of MERS-CoV associated with health-care facilities. 77 The establishment of robust public health infrastructures, effective global consortia to enable rapid and effective detection, definitions and surveillance of new infectious disease threats, and the prioritisation of research, preparedness, response, and control efforts is crucial.…”

Section: Discussionmentioning

confidence: 99%

“…[43][44][45] Human to human transmission has been described within primary community settings and households, 20,32,45,46 but has been more striking within health-care settings. [28][29][30][31][47][48][49][50][51] Healthcare associated outbreaks have occurred in several countries, with the largest outbreaks seen in Saudi Arabia, the United Arab Emirates, and South Korea. 28…”

Section: Person-to-person Transmissionmentioning

confidence: 99%

Middle East respiratory syndrome coronavirus: risk factors and determinants of primary, household, and nosocomial transmission

Hui

Azhar

Kim

et al. 2018

The Lancet Infectious Diseases

388

327

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Middle East respiratory syndrome coronavirus (MERS-CoV) is a lethal zoonosis that causes death in 35·7% of cases. As of Feb 28, 2018, 2182 cases of MERS-CoV infection (with 779 deaths) in 27 countries were reported to WHO worldwide, with most being reported in Saudi Arabia (1807 cases with 705 deaths). MERS-CoV features prominently in the WHO blueprint list of priority pathogens that threaten global health security. Although primary transmission of MERS-CoV to human beings is linked to exposure to dromedary camels (Camelus dromedarius), the exact mode by which MERS-CoV infection is acquired remains undefined. Up to 50% of MERS-CoV cases in Saudi Arabia have been classified as secondary, occurring from human-to-human transmission through contact with asymptomatic or symptomatic individuals infected with MERS-CoV. Hospital outbreaks of MERS-CoV are a hallmark of MERS-CoV infection. The clinical features associated with MERS-CoV infection are not MERS-specific and are similar to other respiratory tract infections. Thus, the diagnosis of MERS can easily be missed, unless the doctor or health-care worker has a high degree of clinical awareness and the patient undergoes specific testing for MERS-CoV. The largest outbreak of MERS-CoV outside the Arabian Peninsula occurred in South Korea in May, 2015, resulting in 186 cases with 38 deaths. This outbreak was caused by a traveller with undiagnosed MERS-CoV infection who became ill after returning to Seoul from a trip to the Middle East. The traveller visited several health facilities in South Korea, transmitting the virus to many other individuals long before a diagnosis was made. With 10 million pilgrims visiting Saudi Arabia each year from 182 countries, watchful surveillance by public health systems, and a high degree of clinical awareness of the possibility of MERS-CoV infection is essential. In this Review, we provide a comprehensive update and synthesis of the latest available data on the epidemiology, determinants, and risk factors of primary, household, and nosocomial transmission of MERS-CoV, and suggest measures to reduce risk of transmission.

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“…The first outbreak which identified the super spreader phenomena was the Korean outbreak, in which a single imported index case resulted in a total of 186 cases. It was thought that 83% of transmission in the Korean outbreak was linked epidemiologically to five super spreaders (Korea Centers for Disease and Prevention, 2015) The same phenomenon was also described in a large outbreak in Riyadh, Saudi Arabia, where 6 out of the 130 cases, contributed to 58.7% of the transmission (Alenazi et al, 2017). However, it remains unclear if an asymptomatic individual who carries MERS-CoV can transmit the virus to others.…”

Section: Human-human Transmissionmentioning

confidence: 85%

Severe Middle East Respiratory Syndrome (MERS) Pneumonia

Alenazi

Arabi

2022

Encyclopedia of Respiratory Medicine

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Identified Transmission Dynamics of Middle East Respiratory Syndrome Coronavirus Infection During an Outbreak: Implications of an Overcrowded Emergency Department

Cited by 36 publications

References 17 publications

Scope and extent of healthcare-associated Middle East respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in Riyadh, Saudi Arabia, 2017

Scope and extent of healthcare-associated Middle East respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in Riyadh, Saudi Arabia, 2017

Middle East respiratory syndrome coronavirus: risk factors and determinants of primary, household, and nosocomial transmission

Severe Middle East Respiratory Syndrome (MERS) Pneumonia

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