MERS-COV (38): SAUDI ARABIA (RIYADH), NOSOCOMIAL TRANSMISSION, WHO

Posted on 13TH JUN 2017
tagged MERS-CoV, Saudi Arabia

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

In this update:
[1] Saudi Arabia, 3 newly confirmed cases/infections, 1 fatality
[2] Saudi Arabia - WHO update 13 Jun 2017

******
[1] Saudi Arabia, 3 newly confirmed cases/infections, 1 fatality
Date: Tue 13 Jun 2017
Source: Saudi MOH 12-13 Jun 2017 [edited]
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/default.aspx?PageIndex=1

As of 14:00 [2:00 PM] today [Tue 13 Jun 2017], there have been a total of:
1657 laboratory-confirmed cases of MERS-CoV infection, including
670 deaths [reported case fatality rate 40.4 percent],
943 recoveries, and
44 currently active cases/infections.

[As previously mentioned, the numbers of deaths, recoveries and currently active cases come from my spreadsheet tallies and differ from those listed on the Saudi MOH website; my spreadsheet counts asymptomatic infections. - Mod.MPP]

Since the last ProMED-mail update [Sun 11 Jun 2017], there have been a total of:
3 newly confirmed cases/infections [including 1 asymptomatic infection in a contact]
1 newly reported fatality, and
0 newly reported recoveries.

Information on newly confirmed cases (3 cases/infections)
- all from Riyadh
- all nosocomial transmission

Date: Tue 13 Jun 2017 (2 cases)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-06-13-0...

1 - A 53-year-old expat female, healthcare worker, currently in stable condition. Classified as a secondary healthcare acquired case in a healthcare worker.

2 - A 58-year-old Saudi male, non-healthcare worker, currently in stable condition. Classified as a secondary healthcare acquired case in a patient.

Date: Mon 12 Jun 2017 (1 asymptomatic infection)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-06-12-0...

3 - A 45-year-old expat female, healthcare worker, currently in stable condition, identified as an asymptomatic contact of previously confirmed MERS-CoV infected individual. Classified as a secondary healthcare acquired case in a healthcare worker.

Information on newly confirmed fatality (1 fatality)
Date: Tue 13 Jun 2017
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-06-13-0...

- A 46-year-old Saudi male, non-healthcare worker with a history of pre-existing co-morbidities. [reported as a newly confirmed case on 3 Jun 2017 at which time he was noted to be in critical condition. Classified as still under investigation at the time of initial confirmation report, but identified as one of the nosocomial transmitted cases by WHO (see case No. 7 in section [2] below). - Mod.MPP]

--
Communicated by:
ProMED-mail

[Hopefully the nosocomial transmission is being interrupted now in Riyadh as there have been fewer cases identified in the past 48 hours (only 3 newly confirmed cases/infections in the past 48 hours as compared with 6, 11, and 8 reported infections in preceding 48 hour intervals. The WHO update in section [2] below helps clarify that there are 3 simultaneous nosocomial outbreaks ongoing in Riyadh at the moment.

After several months with minimal identified nosocomial transmission, one can't help but wonder what has occurred in Saudi Arabia to explain these ongoing transmission chains. - Mod.MPP]

******
[2] Saudi Arabia - WHO update 13 Jun 2017
Date: 13 Jun 2017
Source: WHO Emergencies preparedness, response, Disease Outbreak News (DONs) [edited]
http://www.who.int/csr/don/13-june-2017-mers-saudi-arabia/en/

Middle East respiratory syndrome coronavirus (MERS-CoV) - Saudi Arabia 13 Jun 2017
--------------------------------------------------------------------------------
Between 1 and 10 Jun 2017, the national IHR focal point of Saudi Arabia reported 35 additional cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection including 3 fatal cases and 1 death among previously reported cases (case number 5 in the Disease Outbreak News published on 6 Jun 2017).

Details of the cases
--------------------
Detailed information concerning the cases reported can be found in a separate document [see chart at end of this section].

A total of 32 of the 35 newly reported cases are associated with 3 simultaneous clusters of MERS, of which 2 are related. A description of the 3 clusters is below.

Cluster 1
A cluster of MERS has been identified in a hospital in Riyadh city, Riyadh Region; 23 cases associated with this cluster thus far and include the 1st identified case (a 47-year-old male reported on [1 Jun 2017]), 14 asymptomatic health care worker contacts, 1 household contact, and 7 hospital contacts who were patients.

Cluster 2
This MERS cluster is occurring in a 2nd hospital in Riyadh City, Riyadh Region. This cluster is related to cluster 1 above. The 1st identified case of this 2nd cluster visited the emergency room of the cluster 1 hospital. He was asymptomatic and following this visit in hospital 1, he continued to receive kidney dialysis sessions in the 2nd hospital. To date, this cluster involves 6 cases, including the case involved in cluster 1, and secondary household and health care worker contacts.

Cluster 3
This MERS cluster is currently occurring in a 3rd hospital in Riyadh city, Riyadh Region. To date the cluster involves the 4 cases including the 1st identified case who reported contacts with dromedary camels and 3 asymptomatic or mild cases that were health care worker contacts.

Public health response
----------------------
The Ministry of Health of Saudi Arabia is evaluating each case and their contacts and implementing measures to limit further human-to-human transmission and bring these outbreaks to a control. These measures include:

- Proper isolation for all confirmed cases;
- Active tracing for all contacts of patients, healthcare workers and community contacts;
- Identification of high and low risk contacts with daily monitoring for all during incubation period of the 14 days and performing laboratory testing for high risk contacts, regardless of the development of symptoms;
- Regular updating of the line list of cases and contacts and conducting epidemiological analysis of data to identify the source of infection, links between patients and reasons for human-to-human transmission within hospitals;
- Searching for suspected cases between patients and healthcare workers based on case definition of the disease;
- Enforcement of strict adherence to proper environmental cleaning, disinfection and terminal cleaning and disinfection for hospital environment with special care in departments where the outbreaks are currently occurring or have occurred;
- Enforcement of visual triage for respiratory diseases in emergency department and outpatient departments and ensure the 24/7 availability of a trained nurse for early detection of patients with respiratory symptoms, and proper documentation in triage forms;
- Extensive training of all healthcare workers on case definition for early detection, implementation of isolation precautions, proper selection, donning and doffing of PPEs, hand hygiene and environmental cleaning and disinfection;
- Ensuring that all healthcare workers tested for N95 fitting (fit test);
- Ensuring availability of infection prevention supplies including hand sanitizer, PPEs, surface disinfectants, portable HEPA filters and fumigation machines;
- Enforcing the implementation of a policy of not allowing healthcare workers to travel without medical clearance to prevent the spread of the virus to other countries.

For cases that report contact with dromedary camels, investigations of MERS-CoV infection in dromedaries is conducted by Ministry of Agriculture officials.

Globally, 2015 laboratory-confirmed cases of infection with MERS-CoV including at least 703 related deaths have been reported to WHO since 2012.

Line listing of newly confirmed cases from 1-10 Jun 2017
Case no. / Date report WHO / City of residence / Age / Sex / HCW / Co-morbidities / Camel exposure / Camel milk / Exposure to other cases / Date of onset of symptoms / Date of hospitalization / Date of lab confirmation / Status / Date of outcome

1 / 2017-06-01 / Riyadh / 47 / M / No / Yes / NA / NA / Yes / 2017-05-26 / 2017-05-28 / 2017-05-30 / Alive
2 / 2017-06-02 / Riyadh / 30 / F / Yes / No / No / NA / Yes / NA / NA / 2017-06-02 / Alive*
3 / 2017-06-02 / Riyadh / 33 / F / Yes / No / NA / NA / Yes / NA / NA / 2017-06-02 / Alive*
4 / 2017-06-02 / Riyadh / 30 / F / Yes / No / No / NA / Yes / NA / NA / 2017-06-02 / Alive*
5 / 2017-06-02 / Jeddah / 51 / M / No / Yes / NA / NA / Yes / 2017-05-28 / NA / 2017-06-02 / Alive
6 / 2017-06-03 / Riyadh / 65 / M / No / Yes / NA / NA / Yes / 2017-06-02 / 2017-05-28 / 2017-06-03 / Deceased / 2017-06-03
7 / 2017-06-03 / Riyadh / 46 / M / No / Yes / No / NA / NA / 2017-06-01 / NA / 2017-06-03 / Alive
8 / 2017-06-03 / Riyadh / 24 / M / No / No / Yes / NA / No / 2017-05-28 / 2017-06-02 / 2017-06-03 / Deceased / 2017-06-03
9 / 2017-06-04 / Riyadh / 46 / M / No / Yes / NA / NA / Yes / NA / NA / 2017-06-03 / Alive*
10 / 2017-06-04 / Riyadh / 27 / M / Yes / No / No / NA / Yes / NA / NA / 2017-06-04 / Alive*
11 / 2017-06-04 / Madinah / 73 / M / No / Yes / Yes / Yes / No / 2017-06-01 / 2017-06-03 / 2017-06-04 / Alive
12 / 2017-06-05 / Riyadh / 66 / F / No / Yes / No / NA / Yes / 2017-06-03 / NA / 2017-06-04 / Alive*
13 / 2017-06-05 / Riyadh / 29 / M / No / No / NA / NA / Yes / NA / NA / NA / Alive*
14 / 2017-06-05 / Riyadh / 32 / F / Yes / No / No / NA / Yes / NA / NA / 2017-06-02 / Alive*
15 / 2017-06-05 / Riyadh / 27 / M / No / NA / No / NA / Yes / 2017-06-03 / 2017-05-27 / 2017-06-04 / Alive
16 / 2017-06-06 / Hofuf City / 45 / M / No / No / NA / Yes / No / 2017-06-01 / 2017-06-04 / 2017-06-05 / Alive
17 / 2017-06-06 / Riyadh / 84 / M / No / Yes / No / NA / Yes / NA / NA / 2017-06-05 / Alive*
18 / 2017-06-06 / Riyadh / 48 / M / Yes / No / No / NA / Yes / NA / NA / 2017-06-04 / Alive*
19 / 2017-06-07 / Riyadh / 35 / F / No / No / No / NA / Yes / NA / NA / 2017-06-06 / Alive*
20 / 2017-06-07 / Riyadh / 42 / F / Yes / NA / No / NA / Yes / 2017-06-03 / NA / 2017-06-06 / Alive
21 / 2017-06-07 / Riyadh / 45 / F / Yes / No / No / NA / Yes / NA / NA / 2017-06-06 / Alive*
22 / 2017-06-07 / Riyadh / 57 / F / No / Yes / No / NA / Yes / NA / NA / 2017-06-06 / Alive*
23 / 2017-06-07 / Riyadh / 39 / M / Yes / No / No / NA / Yes / NA / NA / 2017-06-06 / Alive*
24 / 2017-06-08 / Riyadh / 30 / F / Yes / No / No / NA / Yes / NA / NA / 2017-06-07 / Alive*
25 / 2017-06-08 / Riyadh / 31 / F / Yes / No / No / NA / Yes / NA / NA / 2017-06-07 / Alive*
26 / 2017-06-08 / Riyadh / 25 / M / Yes / No / No / NA / Yes / NA / NA / 2017-06-07 / Alive*
27 / 2017-06-08 / Riyadh / 58 / M / No / Yes / No / No / Yes / NA / 2017-05-31 / 2017-06-07 / Alive
28 / 2017-06-08 / Riyadh / 48 / M / No / Yes / No / No / Yes / NA / 2017-05-30 / 2017-06-07 / Alive
29 / 2017-06-09 / Riyadh / 26 / F / Yes / No / No / NA / Yes / NA / NA / 2017-06-08 / Alive*
30 / 2017-06-09 / Riyadh / 28 / F / Yes / No / No / NA / Yes / NA / NA / 2017-06-08 / Alive*
31 / 2017-06-09 / Riyadh / 31 / F / Yes / No / No / NA / Yes / NA / NA / 2017-06-08 / Alive*
32 / 2017-06-09 / Riyadh / 34 / F / Yes / No / No / NA / Yes / NA / NA / 2017-06-08 / Alive*
33 / 2017-06-09 / Riyadh / 48 / F / Yes / No / No / NA / Yes / NA / NA / 2017-06-07 / Alive*
34 / 2017-06-09 / Riyadh / 27 / F / Yes / No / No / NA / Yes / NA / NA / 2017-06-08 / Alive*
35 / 2017-06-10 / Riyadh / 32 / M / No / Yes / No / NA / NA / 2017-06-02 / 2017-05-16 / 2017-06-04 / Deceased / 2017-06-10

* asymptomatic contact

--
Communicated by:
ProMED-mail

[According to this most recent WHO update on MERS-CoV, as of 10 Jun 2017 there have now been 2015 laboratory confirmed cases of MERS-CoV infection reported to WHO, including at least 703 related deaths, with Saudi Arabia having reported 1649 (81.8 percent) cases including 669 (95.2 percent) deaths. Additional information provided in the above reports is the existence of ongoing nosocomial transmission chains in 3 separate healthcare facilities with an apparent relation between 2 of the 3 facilities. The text above seems to suggest there was a possible asymptomatic contact that was in the emergency room of one hospital who then continued receiving renal dialysis at another hospital where he presumably began a 2nd chain of transmission. Unfortunately, the line listing accompanying this update does not "connect the dots" of the 3 transmission chains to enable actually tracing the chains of transmission.

In the previous WHO update from 6 Jun 2017, there was mention of 3 clusters of transmission of which one occurred in Riyadh city (the other 2 clusters involved Bisha and Wadi Aldawasir, the latter in Riyadh province). According to that update:

"Cluster 2
A cluster of cases has been identified in a hospital in Riyadh city, Riyadh Region. Cases associated with this cluster are:
1st identified fatal case: A 55-year-old male reported to WHO on 14 May 2017.
Secondary case - Healthcare contact: A 33-year-old male reported to WHO on 15 May 2017.
Secondary case - Healthcare contact: A 30-year-old female reported to WHO on 15 May 2017.
Secondary case - Healthcare contact: A 25-year-old female reported to WHO on 16 May 2017.
Secondary case - Healthcare contact: A 38-year-old male reported to WHO on 17 May 2017.

According to this update, the 3 chains of transmission began on 1 Jun 2017. One presumes that the 3 hospital outbreaks reported in today's update are not related to the earlier nosocomial outbreak reported in the middle of May 2017.

Additional information on the 35 cases reported above is that case no.7 was reported as a fatality in today's Saudi MOH update (see section [1] above), and case no.27 was possibly the case reported as a recovery on 9 Jun 2017.

We await further clarifications on these transmission chains.

As mentioned above, one can't help but wonder what has occurred in Saudi Arabia to explain these ongoing nosocomial transmission chains after months of limited to none nosocomial transmission chains.

The HealthMap/ProMED map of Saudi Arabia can be found at: http://healthmap.org/promed/p/131. - Mod.MPP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/59685.]

See Also

MERS-CoV (37): Saudi Arabia (RI), nosocomial transmission, fatal 20170611.5098598
MERS-CoV (36): Saudi Arabia (RI), nosocomial transmission
MERS-CoV (35): Saudi Arabia (RI), nosocomial and household transmission 20170608.5093008
MERS-CoV (34): Saudi Arabia, UAE, Qatar, WHO 20170606.5087888
MERS-CoV (33): Saudi Arabia (RI), nosocomial transmission 20170605.5085681
MERS-CoV (32): Saudi Arabia (RI,MD) 20170604.5083353
MERS-CoV (31): Saudi Arabia (MK,RI) nosocomial transmission 20170604.5082194
MERS-CoV (30): Saudi Arabia (RI,MD,MK) 20170602.5077920
MERS-CoV (27): Saudi Arabia (RI,AS,QS) nosocomial transmission 20170519.5049088
MERS-COV (26): Saudi Arabia, EMRO update, RFI 20170514.5032286
MERS-CoV (25): Saudi Arabia, Qatar, WHO 20170428.5002073
MERS-CoV (24): UAE (AZ), Saudi Arabia (RI), WHO 20170425.4993929
MERS-CoV (22): UAE (AZ), Saudi Arabia (RI,MK) Qatar, RFI 20170415.4971825
MERS-CoV (21): Egypt, animal reservoir, camel, ex Sudan, control, RFI 20170405.4948727
MERS-CoV (20): Qatar, Saudi Arabia, WHO 20170404.4947466
MERS-CoV (10): Saudi Arabia (SH, MK) 20170202.4811346
MERS-CoV (09): Saudi Arabia (MK) WHO 20170127.4797694
MERS-CoV (08): Saudi Arabia (MK, RI) 20170125.4792072
MERS-CoV (06): Saudi Arabia, WHO 20170119.4775249
MERS-CoV (05): Saudi Arabia (NJ, SH, RI), RFI 20170114.4766221
MERS-CoV (04): Saudi Arabia (MK, QS), nosocomial outbreak, RFI 20170110.4754928
MERS-CoV (03): Saudi Arabia (SH) & clarification 20170108.4750515
MERS-CoV (02): Saudi Arabia (QS) nosocomial transmission 20170107.4748974
MERS-CoV (01): Saudi Arabia (QS,RI,MD), RFI 20170105.4744802
2016
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MERS-CoV (123): Saudi Arabia (MK, AS) new cases 20161231.4734758
MERS-COV (01): Oman, Saudi Arabia 20160105.3911188
2015
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MERS-COV (167): acute management and long-term survival 20151231.3904300
MERS-CoV (01): Saudi Arabia, new cases, new death 20150104.3069383
2014
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MERS-CoV (69): Saudi Arabia, new case, RFI 20141230.306305
MERS-CoV (01): Bangladesh, KSA, Algeria, UAE, Iran, WHO, RFI 20140616.2541707
MERS-CoV - Eastern Mediterranean (82): anim res, camel, seroepidemiology 20140613.2537848
MERS-CoV - Eastern Mediterranean (01): Saudi Arabia, UAE, Oman, WHO 20140103.2150717
2013
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MERS-CoV - Eastern Mediterranean (106): animal reservoir, camel, Qatar, OIE 20131231.2145606
MERS-CoV - Eastern Mediterranean: Saudi Arabia, new case, RFI 20130518.1721601
Novel coronavirus - Eastern Mediterranean (29): MERS-CoV, ICTV nomenclature 20130516.1717833
Novel coronavirus - Eastern Mediterranean: bat reservoir 20130122.1508656
2012
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Novel coronavirus - Eastern Mediterranean (06): comments 20121225.1468821
Novel coronavirus - Eastern Mediterranean: WHO, Jordan, conf., RFI 20121130.1432498
Novel coronavirus - Saudi Arabia (18): WHO, new cases, cluster 20121123.1421664
Novel coronavirus - Saudi Arabia: human isolate 20120920.1302733
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