Communication critical in tracking down HCWs exposed to MERS
Screening and isolation practices should be hard-wired’ into triage
With health care workers in the bull’s eye of Middle East Respiratory Syndrome (MERS), hospitals preparedness was recently tested by the first two U.S. cases in Indiana and Florida. The real-world situation revealed one critical element of a response plan: Communication.
The second U.S. MERS patient was a health care worker working and living in Saudi Arabia who was visiting Orlando, FL. In the hours before MERS was suspected, some employees in the emergency department at Dr. P. Phillips Hospital, where he sought treatment, had unprotected exposures.
With the help of nurse managers, the hospital quickly identified those exposed employees, says Ken Michaels, MD, MPH, medical director of occupational health at Orlando Health, the parent health system. Two physicians and 14 employees at Dr. P. Phillips Hospital were placed on home isolation for 14 days. Another six employees and one physician at Orlando Regional Medical Center were furloughed after it was discovered they were exposed when the patient accompanied a friend to the radiology department there.
Daily phone calls to exposed employees helped assuage fears, and use of a mobile occupational health clinic at the hospital made testing quick and convenient, Michaels says.
"We wanted to make sure they had an avenue to ask questions, to be heard," says Michaels, who personally called each furloughed employee every day to ask about any symptoms and to respond to any concerns. "I really think that made a tremendous difference. It was very reassuring for them."
Two Orlando employees developed respiratory symptoms shortly after the exposure, but they tested negative for MERS. The symptoms were coincidental, Michaels says. The median incubation period for MERS is five days, and the range is two to 13 days, CDC reports.
Fifty-three health care workers had been placed on home isolation in Indiana after the first MERS case was identified at Community Hospital in Munster, involving a patient who also had been working at a hospital in Saudi Arabia. Worldwide, about 20% of all MERS cases are among health care workers, according to the Centers for Disease Control and Prevention.
Raise the index of suspicion
For the hospitals in Indiana and Florida, MERS underscored the importance of infection control basics, says Michaels. Health care workers wore fit-tested N95s, goggles, gowns and gloves when caring for the MERS patients in negative-pressure rooms. CDC has recommended standard, contact and airborne precautions for suspected or confirmed MERS patients. (See MERS checklist, p.75.)
Most importantly, CDC advised health care providers to ask patients with respiratory symptoms and fever about any travel to the Arabian Peninsula or contact with people who have traveled there.
Five airports in the United States receive 75% of the air travelers from Saudi Arabia; about 100,000 people were expected to fly through Washington, DC, New York, Los Angeles, Atlanta, and Chicago in May and June 2014 alone. But as the first U.S. cases demonstrate, the travelers continue on to many other communities. The Orlando patient had taken four flights from Saudi Arabia.
"While certain cities might appear at higher risk to receive travelers from the Arabian Peninsula, all health care facilities around the United States need to be aware that they could receive an unexpected traveler from the Arabian peninsula and they need to be prepared [to respond]," says David Kuhar, MD, medical officer with CDC’s Division of Healthcare Quality Promotion.
After the first U.S. case and amid a rise in cases in Saudi Arabia, CDC issued a health advisory urging health care providers "to increase their index of suspicion to consider MERS-CoV infection in travelers from the Arabian Peninsula and neighboring countries."
"It’s very important for people to be aware of the possibility of encountering people who are infected with this disease," says Kuhar.
A possible case of MERS put Vanderbilt University Medical Center on alert and essentially served as a very realistic drill. A child with fever and respiratory symptoms who had recently been hospitalized in Saudi Arabia was transferred to Vanderbilt from another U.S. hospital just two days after the first U.S. case emerged in Indiana.
Employees caring for the patient used the recommended enhanced precautions, but Vanderbilt still planned to monitor their health twice daily. The Tennessee health department tested the patient’s samples within hours of admission and found them to be negative for MERS.
"Our plan was to have an electronic log using a survey tool that we would send to the participants every day for them to log their temperatures and symptoms and to remind them to call us should they develop any symptoms," says Melanie Swift, MD, director of the Vanderbilt Occupational Health Clinic.
Vanderbilt had convened an emergency preparedness group when the number of MERS cases began to spike this spring in Saudi Arabia and the United Arab Emirates. The medical center updated protocols, checked the stockpile of personal protective equipment, and added travel questions to the screening of patients.
Patients who come to the emergency department with a febrile respiratory illness are asked to wear a mask, Swift says. "It’s a good time to revisit those screening and early source isolation practices that really should be hard-wired in to how we triage patients anyway," she says.
Hospital spread linked to poor IC
The MERS virus is similar to the SARS virus, another coronavirus that emerged suddenly in 2003. However, the mode of transmission of MERS is not understood and it is not clear whether "super-spreading" may play a role in hospital outbreaks, as it did with SARS.
In all reported cases, there have been direct or indirect links with seven countries: Saudi Arabia, UAE, Qatar, Oman, Jordan, Kuwait, and Yemen, according to the CDC. Concerns about transmission were highlighted by the case of an Illinois man who was a business associate of the Indiana patient and initially seemed to test positive for MERS antibodies. Further testing showed that he had not been infected with MERS, the CDC said.
The spread of MERS in Saudi Arabian hospitals has been associated with inadequate infection control, says Scott McNabb, PhD, MS, research professor with the Rollins School of Public Health at Emory University in Atlanta and a public health consultant and adjunct professor with the King Saud Bin Abdulaziz University for Health Sciences in Riyadh. Emory has a partnership with the Saudi Ministry of Health and is assisting with MERS investigations and infection control.
"In the hospitals where this has proliferated, there has not been the type of global best practices for hospital infection prevention and control," McNabb says. "If all hospitals maintained the minimum standards, then I think we would be able to contain this."
McNabb’s advice to US hospitals to prevent potential MERS exposures from an undiagnosed case: "Go back to the basics and look at exactly what the [CDC] recommendations are."
CDC checklist for MERS preparedness
The Centers for Disease Control and Prevention provided this checklist to help health care facilities prepare for MERS-CoV. It corresponds with CDC guidance but doesn’t represent mandatory requirements, the agency said.
• Ensure facility infection control policies are consistent with the CDC guidance available at www.cdc.gov/coronavirus/mers/infection-prevention-control.html.
• Review procedures for rapidly implementing appropriate isolation and infection practices for potential MERS-CoV patients.
• Review policies and procedures for screening and work restrictions for exposed or ill health care personnel (HCP) including ensuring that HCP have ready access, including via telephone, to medical consultation.
• Review procedures for laboratory submission of specimens for MERS-CoV testing.
• Review plans for implementation of surge capacity procedures and crisis standards of care.
• Develop plans for visitor restriction if MERS-CoV is circulating in the community.
• Ensure that specific persons have been designated within the facility who are responsible for communication with public health officials and dissemination of information to other HCP at the facility.
• Confirm the local or state health department contact for reporting MERS-CoV cases and confirm reporting requirements.
• Assure ability to implement triage activities based on public health guidance including at the facility and using remote (i.e., phone, internet-based) methods where appropriate to minimize demand on the health care system.
• Ensure that negative-pressure airborne infection isolation rooms are functioning correctly and are appropriately monitored for airflow and exhaust handling.
• Ensure that HCP who will provide patient-care have been medically cleared, fit-tested, and trained for respirator use.
• Provide education and refresher training to HCP regarding MERS-CoV diagnosis, how to obtain specimen testing, appropriate PPE use, triage procedures including patient placement, HCP sick leave policies, and how and to whom MERS-CoV cases should be reported, procedures to take following unprotected exposures (i.e., not wearing recommended PPE) to suspected MERS-CoV patients at the facility.
• Assess availability of personal protective equipment (PPE) and other infection control supplies (e.g., hand hygiene supplies) that would be used for both healthcare personnel (HCP) protection and source control for infected patients (e.g., facemask on the patient).
• Have contingency plans if the demand for PPE or other supplies exceeds supply.
• Assess effectiveness of environmental cleaning procedures (www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html) and provide education/refresher training for cleaning staff.
• Monitor the situation at CDC’s MERS website at www.cdc.gov/coronavirus/mers/index.html.