EDs on heightened alert for MERS-CoV as first cases reach the US
Public health experts emphasize importance of travel history, strict adherence to infection control practices
With cases of the Middle East Respiratory Syndrome coronavirus (MERS-CoV) now confirmed in the United States, EDs across the country are on heightened alert for any patients who present with the kind of respiratory distress that is typical of the virus — especially in people who have recently traveled to the Arabian Peninsula or have been in close contact with another confirmed or probable case of MERS-CoV.
The concern is well placed. While there have only been a small number of MERS-CoV cases identified here, there was a brief, but strong surge of cases in the Middle East this spring, possibly due to seasonal variation, according to the World Health Organization (WHO), which has been tracking the virus. Further, health care workers make up a large percentage of these cases, with most human-to-human transmission occurring in the hospital setting.
While MERS-CoV has not yet been as contagious as seasonal influenza or the severe acute respiratory syndrome (SARS) that started in China and then swept around the globe in 2003, it is more deadly. As of early May, WHO reported that the global total of confirmed cases of MERS-CoV stood at 514 cases, with 142 confirmed deaths from the virus.
It’s the type of infectious threat that needs to be taken very seriously, according to public health officials. And thus far, at least, emergency professionals in the United States appear to be well-prepared.
Be alert to red flags
Given the extensive global travel that takes place between the United States and the Arabian Peninsula on a daily basis, infectious disease experts at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA, knew it was just a matter of time before a case of MERS-CoV was identified in the United States. That happened at the end of April when a health care worker who had traveled to the United States from Riyadh, Saudi Arabia, presented to the ED at Community Hospital in Munster, IN, with severe respiratory symptoms.
"The patient was seen by a physician and then had a good number of tests ordered," explains Alan Kumar, MD, chairman and medical director of the Department of Emergency Medicine and chief medical information officer at Community Healthcare System, the parent organization for Community Hospital. "Along the course of care, the diagnosis initially of pneumonia was made, and the patient was admitted to a private room upstairs for further workup and care."
The suspicion that the patient might have MERS-CoV didn’t come up until the next day when the patient and his family were interviewed by an infectious disease specialist on the hospital’s staff. "That is when further isolation measures were taken and the patient was put on full precaution," says Kumar.
Fortunately, the patient was cared for in a negative airflow room — both while in the ED as well as up on an inpatient floor. That was all serendipitous because only eight of the 30 rooms in the ED are negative airflow rooms, explains Kumar. "We don’t have enough [of those rooms] for every patient. But we always want private rooms for patients who have infectious problems, and that was able to be arranged for the patient’s entire stay," he explains. "We don’t automatically go on full precaution unless we suspect a truly infectious, contagious virus, whether it is something more common like influenza or something involving an outbreak in the Midwest like measles, or something rare like MERS-CoV."
The red flags that prompted the hospital to test for MERS-CoV included the fact that the patient had traveled to the United States from Saudi Arabia within the previous 14 days, and he was also a health care professional who had worked at a hospital that was caring for patients with the virus.
Once testing confirmed that the patient did indeed have MERS-CoV, the hospital attempted to identify every person in the hospital who may have been exposed prior to full precaution, explains Kumar. This process was facilitated by the hospital’s extensive video surveillance system that enabled administrators to view the patient’s path, from arrival in the ED to triage and then into the treatment area and a private room. "We also have an RFID badge system, so all of our nurses and patient care technicians wear a radio frequency ID tracer tag that tells us in the ED what room they are in," explains Kumar. "It connects to a call light system so if a patient hits the call light and [a nurse or patient care technician] responds to the room, the call light automatically turns to off."
The RFID system also enabled investigators to determine how long clinicians or other staff members were in the patient’s room right down to the second, says Kumar. "The system is deployed throughout the entire hospital," he observes. "This is the first time the CDC has had this level of detailed data that very clearly delineate exposure time."
Establish lines of communication
As a result of this review, a total of 50 hospital employees including nurses, phlebotomists, respiratory therapists, radiology staff, and employees from several other departments were all tested for MERS-CoV. Further, even though the tests all came back negative for the virus, the employees were all sent home for a full two weeks to prevent any potential transmission of the virus. "The incubation period for this virus is two to 14 days, although the vast majority of exposed individuals develop symptoms within five days," explains Kumar. After 14 days, all the employees who had been sent home were retested to ensure they were still negative for the virus and then allowed to return to work.
Doing without 50 employees is challenging, but Kumar notes that Community Hospital is a large, 467-bed facility with an ED that sees 65,000 patients a year, so it probably has more flexibility to handle this type of disruption than a smaller hospital might have. "We were able to stretch and fill those shifts, and keep operations going as if we were never impacted at all, even though there was a significant amount of scheduling work required," he says.
A larger challenge was managing information about this case so that the community was informed but not overly alarmed. "There was significant collaboration between [the hospital] administration, myself, and the rest of the medical team involved," explains Kumar, noting that the CDC and the Indiana State Department of Health were also in the loop. "We worked very hard to keep the messaging on point and to make sure there was no conflicting data going out."
As soon as the CDC confirmed that the patient had MERS-CoV, there was an educational briefing to management staff throughout the hospital. "They then went out and informed their staff, and we had daily press releases to the public," says Kumar. "We also got help from an outside media firm to make sure that the message was consistent and clear for reassurance and to prevent any type of panic."
Not long after the first case of MERS-CoV was identified in Indiana, a second case was confirmed at Dr. P. Phillips Hospital in Orlando, FL. This case, too, involved a health care worker from Saudi Arabia. Also similar to the Indiana case: Health care workers who treated the patient before the hospital took full MERS-CoV precautions were tested for the virus and then sent home for 14 days, according to the hospital administrators.
Raise awareness, get travel history
While there is no approved treatment for MERS-CoV other than supportive care, both patients who tested positive for MERS-CoV in the United States have since recovered from the virus and have been released. Further, in the process of tracking down everyone who may have come into contact with these patients, the CDC discovered that one patient who was a business associate of the patient in Indiana initially tested positive for antibodies to MERS-CoV, although additional testing showed that this person did not have the virus.
While the investigation into these cases continues, public health experts note that these early experiences have already illustrated why frontline practitioners need to be vigilant in adhering to best practices with respect to infection control. "The biggest thing these two cases have done is they have drawn attention to the issue and raised awareness," observes David Kuhar, MD, a medical officer in the Division of Healthcare Quality Promotion at the National Center for Emerging and Zoonotic Infectious Diseases at the CDC. "We are still learning about MERS-CoV, and we are still learning about the cases being reported; however, we don’t know at this time if there are undocumented cases in these regions and how many people out there may have mild disease rather than severe disease."
Systems for the rapid triage of patients and eliciting symptoms of respiratory infection and fevers may be fairly standard practices, but the early identification of MERS-CoV requires a little more digging, says Kuhar. "The important things here are to be familiar with the case definitions, to be aware of MERS-CoV, and then to not only get the medical history when you are triaging a patient who is presenting with fever, pneumonia, or respiratory distress, but also the travel history," he explains.
Travel to countries in or near the Arabian Peninsula within 14 days of symptom onset or close contact with another known case of MERS-CoV should help to set in motion infection control precautions sooner rather than later, explains Kumar. "We recommend standard contact and airborne precautions so that testing for MERS-CoV can be started," he says.
Bolster existing screens
Hany Atallah, MD, the chief of emergency medicine in the Grady Health System in Atlanta, GA, believes it is only a matter of time before clinicians encounter a patient who is at least at risk for MERS-CoV. To ensure that such a case is identified quickly, the hospital has added questions to a cough screen that it uses to identify potential cases of tuberculosis.
"When people come in we ask them about their cough symptoms — how long they have been coughing, whether they have been exposed to anyone else with TB, and whether they have other risk factors," he explains. Now the hospital is adding questions about whether the patient has been to the Arabian Peninsula within 14 days of the onset of symptoms or whether he or she has been exposed to anyone else who has been to the Arabian Peninsula, says Atallah.
"If a patient is identified as being at risk [for MERS-CoV], there will be an institutional response in that we will place the patient in an appropriate level of isolation. Right now, we [aren’t sure] how MERS- CoV is transmitted, so we will put them in both contact and respiratory isolation in addition to standard precautions," explains Atallah. "We will notify our infectious disease specialist and the hospital epidemiologist, who can then take it from there and let us know what they think."
While the Grady ED sees plenty of patients with respiratory problems, clinicians have not yet come across a patient who has recently traveled from the Arabian Peninsula, but Atallah acknowledges that being on guard for this type of infectious threat is a challenge. "We have a very large hospital that is very close to the busiest airport in the world," he says. "The biggest concern is that we will get so focused on taking care of the patient that we forget about the common sense things in terms of protecting ourselves so the thing we want to emphasize to the staff is that they’ve got to protect themselves."
If, like Community Hospital in Munster, IN, Grady finds itself in a situation in which scores of employees need to be sent home for two weeks because they have been potentially exposed to a person who has tested positive for MERS-CoV, then appropriate plans are in place to do just that, says Atallah. "The last thing our patients need is to come to the hospital and get sicker by contracting something from a health care worker, so that is something we take very seriously," he says. "It is never going to be easy but will do whatever is needed to make sure our patients are kept safe."
Check and re-check protocols
Administrators at Community Hospital have already learned from their first experience in managing a case of MERS-CoV. "One of the things we found in our evaluation is that some of the batteries in our RFID badges had run out," says Kumar. "They had worn all the way down and there is no warning system when a battery is about to wear out, so we have put practices in place so that we can make sure that the batteries are functional at all times."
Administrators also discovered that all the universal and standardized processes they had put in place to handle an infectious process worked well during this case. "These were things we were comfortable doing because we do them every day," says Kumar.
Consequently, Kumar’s advice to colleagues is to make sure proper protocols are in place, follow those protocols, check to make sure you are following those protocols, and then re-educate at appropriate intervals to make sure things are done properly. "One of the main reasons we were able to contain the outbreak so well was strict adherence to the policies in place," he says.
Editor’s note: For case definitions, infection control recommendations, and frequently asked questions about MERS-CoV, visit the CDC’s web page on the virus at: http://www.cdc.gov/coronavirus/mers/hcp.html.
- Hany Atallah, MD, Chief of Emergency Medicine, Grady Health System, and Assistant Professor, Emergency Medicine, Emory University, Atlanta, GA. E-mail:
- David Kuhar, MD, Medical Officer, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA. E-mail: firstname.lastname@example.org.
- Alan Kumar, MD, chairman and medical director, Department of Emergency Medicine, and Chief Medical Information Officer, Community Healthcare System, Munster, IN. Phone: 219-836-4511.