MERS-COV (42): SAUDI ARABIA (RIYADH, ASH SHARQIYAH, AL MADINAH), WHO

Posted on 28TH 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, 4 new cases, 4 new deaths - Saudi MOH 19-27 Jun 2017
[2] Saudi Arabia - WHO update 19 Jun 2017 11-15 Jun 2017

******
[1] Saudi Arabia, 4 new cases, 4 new deaths - Saudi MOH 19-27 Jun 2017
Date: Tue 27 Jun 2017
Source: Saudi MOH 19-27 Jun 2017 [edited]
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/default.aspx?PageIndex=1

As of today [Tue 27 Jun 2017], there have been a total of:
1671 laboratory-confirmed cases of MERS-CoV infection, including
677 deaths [reported case fatality rate 40.5 percent],
968 recoveries, and
26 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.

Of note is that there were no reports available during the period 19-26 Jun 2017, with delayed reporting available on 26 Jun 2017. The delayed reports include information for all dates except 24 and 26 Jun 2017. For the purposes of this current update I am treating 24 and 26 Jun 2017 as days with 0 newly confirmed cases, 0 newly reported deaths and 0 newly reported recoveries. - Mod.MPP]

Since the last ProMED-mail update [Published 20 Jun 2017, but covering the period 16-18 Jun 2017], there have been a total of:
4 newly confirmed cases/infections
4 newly reported fatalities, and
14 newly reported recoveries.

Information on newly confirmed cases (4 cases)
Date: Sun 25 Jun 2017 (1 case)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-06-25-0...

1 - A 30-year-old Saudi female, non-healthcare worker from Dammam [Ash Sharqiyah region] currently in critical condition. Classified as a primary case with a history of indirect contact with camels in the 14 days preceding onset of illness.

Date: Fri 23 Jun 2017 (1 case)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-06-23-0...

2 - A 70-year-old Saudi male, non-healthcare worker from Riyadh [Riyadh region], currently in critical condition. Pending classification as still under investigation (although no history of contact with camels in the 14 days preceding onset of illness).

Date: Thu 22 Jun 2017 (1 case)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-06-22-0...

3 - An 85-year-old Saudi male, non-healthcare worker from Yanbua [Al Madinah region], reported to have died at the time of initial confirmation report [see fatality no. 3 below]. Classified as a primary case with no history of contact with camels in the 14 days preceding onset of illness.

Date: Mon 19 Jun 2017 (1 case)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-06-19-0...

4 - A 42-year-old expat male, non-healthcare worker, from Riyadh [Riyadh region] noted to be in stable condition, having been identified as an asymptomatic household contact of a MERS-CoV infected individual. Classified as a secondary case in a household contact.

Information on newly confirmed fatalities (4 fatalities)
Date: Sun 25 Jun 2017 (1 fatality)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-06-25-0...

1- A 79-year-old Saudi male, non-healthcare worker from Riyadh [Riyadh region], with a history of pre-existing co-morbidities. [Reported as a newly confirmed case on 15 Jun 2017 at which time he was noted to be in stable condition. Classified as a secondary healthcare acquired case in a patient. - Mod.MPP]

Date: Fri 23 Jun 2017 (1 fatality)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-06-23-0...

2- A 47-year-old expat male from Riyadh [Riyadh region], with no a history of pre-existing co-morbidities. [Reported as a newly confirmed case on 1 Jun 2017 at which time he was noted to be in critical condition. Classified as a primary case with high risk exposure history in the 14 days preceding onset of illness still under investigation. - Mod.MPP]

Date: Thu 22 Jun 2017 (1 case)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-06-22-0...

3- An 85-year-old Saudi male, non-healthcare worker from Yanbua [Al Madinah region] with a history of pre-existing co-morbidities. [Reported as a newly confirmed case on 22 Jun 2017 (see case no. 3 above), at which time he had been reported to have died. Classified as a primary case with no history of contact with camels in the 14 days preceding onset of illness. - Mod.MPP]

Date: Wed 21 Jun 2017 (1 case)

[In the 9 day interval since the last update, there have been a total of 4 newly confirmed cases of MERS-CoV infection reported from Saudi Arabia, none of whom are reported to be associated with the nosocomial transmission chains that were ongoing in Riyadh. 2 of the 4 newly confirmed cases were from Riyadh, one of whom was identified as an asymptomatic household contact of a previously confirmed case. The other 2 cases came from Yanbua in Al Madinah Region and Damman in Ash Sharqīyah [Eastern Region]. There were 4 newly reported fatalities in this period, and most notable were the 14 reported recoveries during this period, 9 of whom were associated with the nosocomial outbreaks ongoing in Riyadh.

Maps showing the locations of the cases can be found at the source URLs. - Mod.MPP]

******
[2] Saudi Arabia - WHO update 19 Jun 2017 11-15 Jun 2017
Date: Mon 19 Jun 2017
Source: WHO Emergencies preparedness, response
http://www.who.int/csr/don/19-june-2017-mers-saudi-arabia/en/

Middle East respiratory syndrome coronavirus (MERS-CoV) - Saudi Arabia 19 Jun 2017
----------------------------------------------------------------------------------
Between [11 and 15 Jun 2017], the national IHR Focal Point of Saudi Arabia reported 14 additional cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection including one fatal case among previously reported cases.

Details of the cases
A total of 13 of the 14 newly reported cases are associated with clusters 1 and 3 in the Disease Outbreak News published on 13 Jun 2017. Seven of the 13 newly reported cases are health care workers.

Cluster 1
This Middle East Respiratory Syndrome (MERS) cluster is currently occurring in a hospital, Riyadh city, Riyadh region. An additional 9 cases have been reported in this cluster including 3 health care workers. In total, 32 laboratory-confirmed cases reported to WHO are associated with this cluster to date. All of the asymptomatic cases are in home isolation and all symptomatic cases are isolated on a hospital ward.

Cluster 2
No newly reported cases are associated with cluster 2 as reported in the Disease Outbreak News published on 13 Jun 2017.

Cluster 3
This MERS cluster is currently occurring in a 3rd hospital in Riyadh city, Riyadh Region. In addition to the cases previously reported in the Disease Outbreak News published on 13 Jun 2017, the cluster involves 4 newly reported cases. To date, this cluster involves, including the suspected index case, 8 laboratory confirmed patients all of them are health care workers, including the 4 newly reported cases described in the separate document (see below).

Globally, 2029 laboratory-confirmed cases of infection with MERS-CoV including at least 704 related deaths have been reported to WHO.

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 (home isolation for asymptomatic patients, in hospital for symptomatic patients).
- Active tracing for all contacts of patients, health care 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; multiple laboratory testing is conducted during the follow-up period.
- 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 MERS-CoV spread in the hospitals.
- Investigation of suspected cases between patients and health care workers based on case definition of MERS.
- Enforcement of strict adherence to proper environmental cleaning, disinfection and terminal cleaning and disinfection for hospital environment with special care to the 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 patient with respiratory symptoms, and proper documentation in triage form.
- Extensive training of all health care 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 health care 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 implementing of a policy of not allowing health care workers to travel without medical clearance to prevent the spread of the virus to other countries.

WHO risk assessment
MERS-CoV causes severe human infections resulting in high mortality and has demonstrated the ability to transmit between humans. So far, the observed non-sustained human-to-human transmission has occurred mainly in health care settings. Preliminary investigations of the clusters described above indicate that secondary cases are linked to 2 events where aerosolizing procedures were conducted in crowded medical wards under sub-optimal infection prevention and control conditions.

The notification of additional cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East, and that cases will continue to be exported to other countries by individuals who might acquire the infection after exposure to animals or animal products (for example, following contact with dromedaries) or human source (for example, in a health care setting). WHO continues to monitor the epidemiological situation and conducts risk assessment based on the latest available information.

WHO advice
Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for acute respiratory infections and to carefully review any unusual patterns. Infection prevention and control measures are critical to prevent the possible spread of MERS-CoV in health care facilities. It is not always possible to identify patients with MERS-CoV early because like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Therefore, health-care workers should always apply standard precautions consistently with all patients, regardless of their diagnosis. Droplet precautions should be added to the standard precautions when providing care to patients with symptoms of acute respiratory infection; contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection; airborne precautions should be applied when performing aerosol generating procedures.

Until more is understood about MERS-CoV, people with diabetes, renal failure, chronic lung disease, and immunocompromised persons are considered to be at high risk of severe disease from MERS-CoV infection. Therefore, these people should avoid close contact with animals, particularly camels, when visiting farms, markets, or barn areas where the virus is known to be potentially circulating. General hygiene measures, such as regular hand washing before and after touching animals and avoiding contact with sick animals, should be adhered to.

Food hygiene practices should be observed. People should avoid drinking raw camel milk or camel urine, or eating meat that has not been properly cooked.

WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.

Line listing of newly confirmed cases from 11-15 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 / 2017-06-11 / Riyadh / 35 / M / Yes / No / No / No / Yes† / NA / NA / 2017-06-10 / Alive
2 / 2017-06-11 / Riyadh / 57 / M / Yes / Yes / No / No / Yes† / 2017-06-07 / 2017-06-08 / 2017-06-10 / Alive
3 / 2017-06-11 / Riyadh / 42 / F / Yes / No / No / No / Yes† / 2017-06-08 / 2017-06-09 / 2017-06-10 / Alive
4 / 2017-06-11 / Riyadh / 54 / F / Yes / No / No / No / Yes† / NA / NA / 2017-06-10 / Alive
5 / 2017-06-11 / Riyadh / 39 / M / Yes / No / No / No / Yes† / NA / NA / 2017-06-10 / Alive
6 / 2017-06-12 / Riyadh / 45 / F / Yes / No / No / No / Yes† / NA / NA / 2017-06-11 / Alive
7 / 2017-06-13 / Riyadh / 58 / M / No / Yes / No / No / Yes† / 2017-06-12 / 2017-05-27* / 2017-06-13 / Alive
8 / 2017-06-13 / Riyadh / 53 / F / Yes / No / No / No / Yes† / 2017-06-11 / 2017-06-12 / 2017-06-13 / Alive
9 / 2017-06-14 / Riyadh / 70 / F / No / Yes / No / No / Yes† / 2017-06-10 / NA / 2017-06-14 / Alive
10 / 2017-06-14 / Riyadh / 59 / M / No / Yes / No / No / Yes† / 2017-06-12 / 2017-05-27* / 2017-06-14 / Alive
11 / 2017-06-14 / Riyadh / 47 / M / No / Yes / NA / NA / NA / 2017-06-06 / 2017-06-11 / 2017-06-13 / Alive
12 / 2017-06-15 / Hail City / 29 / M / No / Yes / No / No / Yes† / 2017-06-12 / 2017-06-14 / 2017-06-15 / Alive
13 / 2017-06-15 / Riyadh / 79 / M / No / Yes / No / No / Yes† / 2017-06-13 / 2017-06-01* / 2017-06-15 / Alive
14 / 2017-06-15 / Riyadh / 67 / M / No / Yes / No / No / Yes† / 2017-06-13 / 2017-05-28* / 2017-06-15 / Alive
†Case was detected through contact tracing of a previous MERS-CoV case.

--
Communicated by:
ProMED-mail Rapporteur Marianne Hopp

[According to the WHO update, there have now been 2029 laboratory confirmed cases of MERS-CoV infection reported globally including at least 704 related deaths reported to WHO.

In summary there are 3 concurrent nocomial outbreaks ongoing in Riyadh involving 3 hospitals in Riyadh. The 1st outbreak/cluster has identified 32 laboratory confirmed cases of whom 9 were identified in the above update. The 2nd outbreak/cluster has not reported new cases in the above update, and the 3rd outbreak/cluster there are 8 laboratory confirmed cases, all of whom are healthcare workers (4 of whom were newly reported in the above update).

Of note in this update is the mention that the nosocomial outbreaks relate to 2 separate events with aerosolizing procedures - a reminder of some of the nosocomial associated super spreader events during the SARS outbreak in 2002-2003.

Additional updated information on cases identified in the above provided line listing is that cases nos. Twelve and 13 were reported to have died - case no.12 on 17 Jun 2017 and case no. Up to 13 on 25 Jun 2017. Cases nos. 9, 10, and 14 were noted to be in critical condition at the time of their initial confirmation reports. Case no.11 is reported in the above report as a 47-year-old, whereas the initial confirmation report on the Saudi MOH website mentions the case is 40-years-old. Cases no. 1, 3, and 8 were reported to have recovered, case no.1 on 17 Jun 2017, case 3 either 22 or 25 Jun Jun 2017 (there were 2 42-year-old female healthcare workers), and case 8 on 23 Jun 2017. And case no.12 is most likely the 29-year-old male reported from Riyadh on the MOH report, whereas the above report has him from Hail in Hail Region.

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/131.]

See Also
MERS-CoV (41): Saudi Arabia (RI, SH) 20170620.5117143
MERS-CoV (40): animal reservoir, camels, review, FAO 20170619.5115999
MERS-CoV (39): Saudi Arabia (RI), nosocomial transmission 20170615.5108781
MERS-CoV (38): Saudi Arabia (RI), nosocomial transmission, WHO 20170613.5102806
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 (20): Qatar, Saudi Arabia, WHO 20170404.4947466
MERS-CoV (10): Saudi Arabia (SH, MK) 20170202.4811346
MERS-CoV (04): Saudi Arabia (MK, QS), nosocomial outbreak, RFI 20170110.4754928
MERS-CoV (02): Saudi Arabia (QS) nosocomial transmission 20170107.4748974
MERS-CoV (01): Saudi Arabia (QS,RI,MD), RFI 20170105.4744802
2016
----
MERS-CoV (123): Saudi Arabia (MK, AS) new cases 20161231.4734758
MERS-COV (01): Oman, Saudi Arabia 20160105.3911188
2015
----
MERS-COV (167): acute management and long-term survival 20151231.3904300
MERS-CoV (01): Saudi Arabia, new cases, new death 20150104.3069383
2014
----
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
----
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
----
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
.................................................mpp/ec/ml