APIC 2014: Saudi IPs say MERS is our challenge,’ but tide is turning with aggressive new measures
We have to be ready around the clock’
By Gary Evans, Executive Editor
The wider availability of PCR tests to rapidly detect MERS coronavirus is enabling hospitals in Saudi Arabia to better identify cases and prevent transmission to patients and health care workers, infection preventionists from the Kingdom tell Hospital Infection Control & Prevention.
Rather than crestfallen at the global attention on the emergence of the novel coronavirus, the Saudi clinicians expressed confidence and a surprising level of pride that it is their fate to be at the epicenter of a possible pandemic.
"It is our challenge — we in infection control and prevention," says Mercy Joseph, BSN, CIC, an infection preventionist at King Fahad Medical City in Riyadh. "Now we have to be ready around the clock. It is a good challenge for us and we enjoy our work a lot. We know we are doing something for the public."
In an exclusive interview in Anaheim at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC), the Saudi clinicians say they are close to turning the tide of MERS and have recently stopped transmission in their hospitals.
"We have gone three weeks with zero cases," Joseph says.
Concurring was Dr. Areej Taher Ben Sadek, an infection preventionist at King Fahad Hospital in Jeddah. "For the last six weeks — and among health care workers for the last two months — we have zero reported cases," she says.
While both Saudi IPs confirmed that they have had MERS transmission in the past to patients and health care workers, one of the key differences now is wider availability of PCR tests that can confirm or rule out MERS in no more than six hours.
"That is really helping us manage the cases," Joseph says. "The lab is one of the main center points of our care. Even at night, we have good communication and they will call us without fail."
Delays in getting confirmed test results have likely led to unprotected exposures to patients and health care workers, says Fiaz Ahamed, MD, MBBS, infection preventionist at Al Rass General Hospital.
"Before there was only one center in one city where they were testing," he says. "Now there are many [testing] centers and they are implementing efficient specimen test protocols to guarantee the validity of tests."
Asked about reported1 breakdowns in infection control in Saudi hospitals, Ahamed says failure to follow all precautions for unconfirmed cases has been part of the problem.
"Sometimes there are breaches in infection control strategies — they may have not been wearing masks or something," he tells HIC. "Actually, the infection control programs are very strong in Saudi Arabia. Once the patient is confirmed there is 100% infection control."
But exposures may occur from suspect patients because until recently, test results may not have been available for 2 to 3 days at many hospitals. "Confirmed cases are placed under isolation that includes negative pressure air ventilation," Ahamed says. "But only the confirmed cases are there, and the suspect cases during this time period could be a source of infection."
The threat to health care workers
Certified in infection control since 2006, Joseph says anyone who comes to her hospital with flu-like symptoms is immediately separated into another area and tested for MERS. "There is no mixing and mingling — we have a really good triage system," she says.
The hospital has seen transmission to health care workers from unsuspected cases, particularly one who did not show any obvious signs of MERs.
"He was not even suspected [as having MERS] and that was the reason he exposed a lot of health care workers," Joseph says. "Only after admission was it suspected, and by that time some employees were exposed."
Another health care worker infected a colleague because the two shared a small apartment, she says. It is estimated that a quarter of MERS cases have been in health care workers, but the vast majority of fatal infections have occurred in patients with chronic underlying conditions.
"We had a few cases of health care workers becoming infected, but they are all fine now," Joseph says.
The first two MERS cases in the U.S. were health care workers who traveled from Saudi Arabia, drawing attention to the large number of workers from other nations who provide medical care in the Kingdom. (See related story, above.) 63.) Health care workers who travel from Saudi Arabia to other nations should be aware of any signs and symptoms of MERS, which has an incubation period for as long as two weeks, Joseph says.
"We know the main important factor is to give them more education," she says. "We tell them if you are leaving this country you have to self-observe for yourself. Even us coming here, we are also exposed to the patients, so we have to do the proper precautions and self-observe."
Some Saudi hospitals are giving incentives like salary supplements to health care workers willing to work with MERS patients, Ahamed says. "But if I am a physician or health care worker and I follow the complete measures of prevention I will be happy to work there. If you follow these measures there is no harm in working."
Al Rass is some 400 miles away from where most cases have been occurring, and thus far Ahamed has primarily dealt with suspect cases. "In my hospital we have had 15 suspect cases, but none of them became positive," he says. "But I do visit hospitals where there are some [MERS] patients. I do rounds and I have been with them and their infection control practitioners."
Though Ahamed did not want to get into health policy matters, many of the initiatives and changes described by the Saudi IPs have come recently under the new leadership of health minister Adel bin Mohammad Faqih. The change has resulted in more transparency and the case count and mortality figures were revised upward after a review of all cases since the outbreak began in 2012. As of June 4, 2014 there were 695 MERS cases and 283 deaths in Saudi Arabia. Other new initiatives under Faqih include an electronic case reporting system, guidelines for the proper labeling and storage of samples in hospitals and labs, protocols to ensure the integrity of samples during transport, and a courier transportation system for rapid transfer of specimens.
"Our country has a lot of resources and all the control measures are being provided," Ahamed says.
Mutable MERS lacks pandemic punch
While a deadly threat to immune compromised patients in hospitals, MERS has not been able to sustain transmission in the community beyond a few reports of families and other close contacts. Many uncounted mild or asymptomatic cases may have occurred, but transmission seems to rapidly dissipate in the community. In the absence of a mutation making it more transmissible — which is certainly a realistic concern given the known mutability of coronaviruses — MERS currently lacks the staying power needed for true pandemic potential.
Last year, for example, researchers compared MERS to SARS using the classic epidemiological measure of reproductive ratio, the expected number of secondary infections from a single case. The reproductive ratio reaches a tipping point for further transmission at 1 or above, indicating secondary infections can sustain an outbreak. Researchers looked at 55 laboratory-confirmed cases of MERS, finding that even in their most "pessimistic scenario," that MERS had a reproductive ratio of .69. They noted that pre-pandemic SARS was in the .80 range, but that coronavirus did apparently mutate and become more transmissible at some point in the outbreak.2 That possibility remains with MERS, which has apparently established a reservoir in camels in the region after likely emerging as a bat-borne virus.
Some Saudi Clinicians are trying to treat MERS cases with an experimental combination of ribavirin and interferon, Ahamed notes. The drug combination had some success against SARS, but the results with MERS have been inconclusive.
"[Overall,] the case fatality rate is about 40% for the confirmed cases," Ahamed says.
The emergence of MERS has led to a dramatic culture change in Saudi Arabia, as the IPs say that people are washing their hands much more frequently in public settings.
"In the schools, the malls, in the Mosques, everywhere now we have [hand hygiene]," says Ben Sadek. "I went to my daughter’s school and they are asked, Please you are a doctor can you give us some education?’ I told them it is not just MERS. It could be meningitis, the flu, we just need to apply hygiene and standard precautions to everything in our lives. Even at home — hand hygiene."
- World Health Organization: WHO concludes MERS-CoV mission in Saudi Arabia. May 7, 2014: http://bit.ly/1fP2kF6
- Breban R, Riou J, Fontanet A. Interhuman transmissibility of Middle East respiratory syndrome coronavirus: Estimation of pandemic risk. Lancet Early Online Publication, 5 July 2013 doi:10.1016/S0140-6736(13)61492
Rapid follow-up, no MERS spread in two U.S. cases
CDC: We will continue to err on the side of caution’
None of the health care workers or other people exposed to the first two MERS cases in the United States were infected, as contacts were subject to rapid follow up and home quarantine policies following the exposures.
For example, in the hours before MERS was suspected in the second U.S. case in Orlando, several employees in the emergency department at Dr. P. Phillips Hospital 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."
The Florida MERS case was confirmed on May 11, 2014, about a week after the first U.S. imported case of MERS was confirmed in Illinois. Both men had recently worked in hospitals in Saudi Arabia. The CDC initially reported the Illinois man transmitted MERS to a business associate from Indiana, but reversed the call after more definitive testing.
"While we never want to cause undue concern among those who have had contact with a MERS patient, it’s our job to move quickly when there’s a potential public health threat," says David Swerdlow, MD, the CDC’s incident manager for MERS response. "Understand that the situation is very fluid and our information may change. Because there is still much we don’t know about this virus, we will continue to err on the side of caution."
