MERS CoV Outbreak Riyadh, July-Aug 2015

What is MERS-CoV?Middle East Respiratory Syndrome Coronavirus• Virus causes severe acute respiratory illness associated with

high mortality• First identified in Jeddah, Saudi Arabia in 2012• Patient died with pneumonia and acute renal failure

• Corona viruses can infect animals and humans in many cases crossing species

• Cause a range of respiratory illnesses from common cold to severe respiratory failure

• SARS (severe acute respiratory coronavirus) was the first corona virus identified as causing critical illness

• 2002-2003 a worldwide outbreak with over 8000 confirmed cases including 774 deaths

MERS-CoV• Majority of cases in Saudi Arabia

(80%)• Camels are believed to be source

of animal to human transmission• High viral loads isolated from

camel respiratory sections• Virus binds to DPP4 receptor on

bronchial, bronchiolar & alveolar epithelial cells

• DPP4 also expressed in kidney

Clinical Picture• Spectrum of disease some

patients asymptomatic• Rapid progressive severe

respiratory failure• With early acute renal failure• severe cases in patients with

significant comorbidities• Presentation non specific: fever

70%, cough 70%, dyspnea 65%, GI symptoms 30%

• Typical presentation: leukopenia, lymphocytopenia, raised creatinine, chest x-ray changes

• Rapid deterioration

King Abdulaziz Medical City

• 1000 Bed University Teaching Hospital• Emergency Department 150 beds • 250,000 visits per year• 7 ICUs approx 80 beds

Mid June – Mid September 2015King Abdulaziz Medical City, Riyadh130 Cases

693 deaths

MERS cases June to Sept 2015130 cases

Patients n=87Mean age 64Saudi 94%Male 64%Chronic Comorbidity 99%Mean number comorbidities 5.6

Healthcare workers n=43(3000 screened, 86% of cases asymptomatic)Mean Age 40Female 77%Philippines 74%Chronic Comorbidity 42%Mean number comorbidities 2

Location at time of MERS infection

ICU admissions with MERS

Patients (n=87) mortality 59%

• Admitted ICU n=55• Ventilated 96%• Mean Ventilator days 11• ICU mortality 93%

• HCW (n=43) no deaths

• Admitted ICU n=8 • Ventilated n=7• Mean Ventilator days 15• ECMO n=1

(72% of HCW were never admitted to hospital)

How to Identify a potential MERS CaseDuring a MERS Outbreak• Any patient with acute

respiratory deterioration after admission is MERS until otherwise proven otherwise

Definitely MERS if: 1) pyrexia with low WCC & 2) deteriorating renal function despite CVS stability

Saudi Arabia not during a MERS Outbreak

• any patient with a cough, fever and/or respiratory distress

Interesting Points• Why do the MERS hospital outbreaks occur?

• What is happening in Saudi Arabia now to stop further outbreaks?

• Is there a take home message for UK A&E and ICU staff?

Why did this MERS hospital outbreak occur?

• Cultural issues• Poor infection control in ER and ICU• ‘Super-spreader’ patients• Problems with the MERS CoV test• Poor leadership / control of outbreak / medical cultural

issues

Why did this MERS hospital outbreak occur?

• Cultural issues• Poor infection control in ER and ICU• ‘Super-spreader’ patients• Problems with the MERS CoV test• Poor leadership / control of outbreak / medical cultural

issues

Poor infection control in ER and ICU• The ER was not like A&E in the UK. • No 4-hour target• ICU in the ER• Nurses in ER not ICU nurses• None of the ICU quality improvement strategies taken to

ER• No bed spaces patients just ventilated on trolleys• Constant turnover of patients• Open area milling with staff, patients and relatives

‘Factors that facilitated the spread of infection in and from the ED included the extreme overcrowding, uncontrolled patient movement, high visitor traffic, non-strict compliance with infection control recommendations, late recognition/isolation of some cases, and HCWs serving on both ED and other hospital locations’

Why did this MERS hospital outbreak occur?

• Cultural issues• Poor infection control in ER and ICU• ‘Super-spreader’ patients• Problems with the MERS CoV test• Poor leadership / control of outbreak / medical cultural

issues

WHO Urgent Mission for the investigation of the outbreak of the MERS in South Korea

Super-spreading events of MERS-CoV infection

‘This nosocomial outbreak was most intriguing, With 82 people (33 patients, 8HCW, and 41 Visitors) being infected following exposure to Patient 14 on May 27–29 in the emergency room’

WHO Urgent Mission for the investigation of the outbreak of the MERS in South KoreaSuper-spreading events of MERS-CoV infection

predisposing factors: 1 failure to implement strict isolation of patients 2 poor communication 3 Overcrowding in ER3 inadequate ventilation 4 limited availability of isolation rooms in ER

Why did this MERS hospital outbreak occur?

• Cultural issues• Poor infection control in ER and ICU• ‘Super-spreader’ patients• Problems with the MERS CoV test• Poor leadership / control of outbreak / medical cultural

issues

Problems with the MERS CoV test• Need to avoid a ‘superspreader’• laboratory diagnosis of MERS-CoV (using RT-PCR) takes

time. • URT samples usually give a false negative result• Often it is only when deep respiratory samples are taken

after intubation that the diagnosis is confirmed. • For these reasons at the time of intubation the diagnosis

of MERS CoV is unknown.

Problems with the MERS CoV testThe WHO guidelines: • Middle Eastern patients with fever cough and either

dyspnea, hypoxemia, chest crackles or radiological infiltrates are ‘probable cases’ of MERS-CoV

• all these patients should be placed in an adequately ventilated single rooms

• Cohorting leads to MERS-CoV transmission

• A case series from 3 ICUs at 2 tertiary care hospitals in Saudi Arabia found that of 114 patients suspected of having MERS-CoV only 10 were confirmed

Why did this MERS hospital outbreak occur?

• Cultural issues• Poor infection control in ER and ICU• ‘Super-spreader’ patients• Problems with the MERS CoV test• Poor leadership / control of outbreak / medical cultural

issues

Poor leadership / control of outbreak / medical cultural issues• Hierarchical management• Tendency to try an bury problems to save face• Blame culture• Lack of expertise and training

Failure to close ER ER finally emptied of patientsOn 22nd of August

Interesting Points• Why do the MERS hospital outbreaks occur?

• What is happening in Saudi Arabia to stop further outbreaks?

• Is there a take home message for UK A&E and ICU staff?

MERS Precautions Rules keep changing!Confirmed MERS & suspected MERS Aerosol producing procedures• Goggles / N95 mask at least / Waterproof gown / Gloves / Shoe

covers• Negative pressure room / Transfer in isolation pod• If possible avoid aerosol procedures such as NIV and nebulizers• Minimise exposure of staff & relatives• Specfic SARI ICU set up for all potential and confirmed cases of

MERS• Two ICUs with all negative pressure cubicles (30 bed spaces)• SARI ICU closes to all other patients if an outbreak

What is happening in Riyadh to prevent further outbreaks?

SARI Clinic• All respiratory symptoms• screening pre ER • Special Respiratory Clinic• Droplet isolation

Interesting Points• Why do the MERS hospital outbreaks occur?

• What is happening in Saudi Arabia to stop further outbreaks?

• Is there a take home message for UK A&E and ICU staff?

Location at time of MERS infection Healthcare Workers• Emergency Department 47%• Wards 23%• ICU 9%• Other/multiple 21%

What can we do to prevent hospital spread of an infectious agent such as MERS ?

• Respiratory Failure

• Initial Resuscitation• High Flow 02, Suctioning, NIV, Nebulisers,

Physio Intubation & Ventilation

• Differential diagnosis

• Risk assessment

• PPE

A&E

ICU

Highest risk ofSpreading infection

PPE

Typical A&E Admission

• Respiratory Failure• Treat as SARI

• PPE for SARI• Droplet protection

• Initial Resucitation• High Flow 02, Suctioning, NIV, Nebulisers, Intubation &

Ventilation

• Differential diagnosis

• Risk assessment

• Reassess need & type of PPE

A&E

ICU

PPE

Typical A&E Admission

The risks are out there

Any Questions?