MERS-COV (48): SAUDI ARABIA (AL QASIM, RIYADH), WHO RISK ASSESSMENT

Posted on 28TH JUL 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, 1 new case - Saudi MOH 12-26 Jul 2017
[2] Global risk assessment - WHO 21 Jul 2017

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[1] Saudi Arabia, 1 new case - Saudi MOH 12-26 Jul 2017
Date: Thu 27 Jul 2017
Source: Saudi MOH 12-27 Jul 2017 [edited]
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/default.aspx

As of today [Wed 26 Jul 2017], there has been a total of:
1676 laboratory-confirmed cases of MERS-CoV infection, including
681 deaths [reported case fatality rate 40.6 percent],
987 recoveries, and
8 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. One complication is the reporting of cases as either recoveries or deaths that cannot be confirmed as a previously reported newly confirmed case (see newly reported recovery #3 below). - Mod.MPP]

Since the last ProMED-mail update [Fri 7 Jul 2017, but with information only through Thu 6 Jul 2017], there has been a total of:
2 newly confirmed cases
1 newly reported fatality, and
7 newly reported recoveries.

Information on newly reported cases (2):
Date: 27 Jul 2017
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-07-27-0...

1- 36-year-old Saudi male, non-healthcare worker from Buraidah [Al Qaṣīm region] currently in critical condition. Classified as a primary case with a history of direct contact with camels in the 14 days preceding onset of illness.

Date: 26 Jul 2017 (1 case)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-07-26-0...

2- A 57-year-old expat male, non-healthcare worker from Riyadh [Riyadh region] noted to be in stable condition. Classified as a primary case with high risk exposure history still under investigation.

Information on newly reported recoveries (7):
Date: 25 Jul 2017 (1 recovery)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-07-25-0...

1 - A 70-year-old Saudi female, non-healthcare worker from Riyadh [Riyadh region] with a history of pre-existing co-morbidities. [reported as a newly confirmed case on Wed 14 Jun 2017 at which time she was noted to be in critical condition. Classified as a secondary healthcare acquired in a patient - Mod.MPP]

Date: 21 Jul 2017 (1 recovery)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-07-21-0...

2- A 30-year-old expat female, healthcare worker from Riyadh [Riyadh region] with no history of co-morbidities. [reported as a newly confirmed case on either 2 or 8 Jun 2017 at which time she was noted to be in stable condition, having been identified as an asymptomatic contact of a laboratory confirmed case of MERS-CoV infection. Classified as a secondary healthcare acquired case in a healthcare worker. - Mod.MPP]

Date: 18 Jul 2017 (1 recovery)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-07-18-0...

3- A 60-year old expat male, non-healthcare worker from Riyadh with a history of pre-existing co-morbidities. [I was unable to identify this case in previously reported cases by the Saudi MOH - Mod.MPP]

Date: 17 Jul 2017 (1 recovery)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-07-17-0...

4- An 84-year-old Saudi male, non-healthcare worker from Riyadh [Riyadh region] with a history of pre-existing co-morbidities. [Reported as a newly confirmed infection on Tue 6 Jun 2017 at which time he was noted to be in stable condition having been identified as an asymptomatic infection in a contact of a laboratory confirmed case of MERS-CoV infection. Classified as a secondary healthcare acquired case in a patient. - Mod.MPP]

Date: 15 Jul 2017 (1 recovery)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-07-15-0...

5- A 70-year-old Saudi male, non-healthcare worker from Baha [Al Bāhah region] with a history of pre-existing co-morbidities. [Reported as a newly confirmed case on Sat 1 Jul 2017 at which time he was noted to be in stable condition. Classification was pending as possible high risk exposures were still under review. - Mod.MPP]

Date: 12 Jul 2017 (1 recovery)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-07-12-0...

6- A 67-year-old expat male, non-healthcare worker from Riyadh [Riyadh region] with a history of pre-existing co-morbidities. [Reported as a newly confirmed case on Thu 15 Jun 2017 at which time he was noted to be in critical condition. Classified as a secondary healthcare acquired case in a patient. - Mod.MPP]

Date: 11 Jul 2017 (1 recovery)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-07-11-0...

7- A 57-year-old Saudi female, non-healthcare worker from Hail [Ḥā'il region] with a history of pre-existing co-morbidities. [Reported as a newly confirmed case on Tue 4 Jul 2017 at which time she was noted to be in stable condition. Classified as a primary case with high-risk exposure history still under investigation. - Mod.MPP

--
Communicated by:
ProMED-mail

[Now that the nosocomial transmission in Riyadh has been interrupted, it appears as though transmission in Saudi Arabia has returned to sporadic cases being reported. There was a 2 week hiatus when there were no new laboratory confirmations of MERS-CoV in the country followed by a single case reported yesterday [Wed 26 Jul 2017] from Riyadh and a single case reported today [Thu 27 Jul 2017] from Buraidah (Al Qasim region). Both classified as primary cases with the former case still under investigation for high-risk exposures and the latter case having a history of direct contact with camels during the 14 days preceding onset.

With these 2 newly confirmed cases, the total number of confirmed infections with MERS-CoV reported by Saudi Arabia is now at 1676 including 681 deaths (reported case fatality rate of 40.6 percent).

Maps showing the locations of the newly reported cases and the reported recoveries during this period can be found at the source URLs. The HealthMap/ProMED map of Saudi Arabia can be found at: http://healthmap.org/promed/p/131. - Mod.MPP]

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[2] Global risk assessment - WHO 21 Jul 2017
Date: Fri 21 Jul 2017
Source: WHO risk assessment 21 Jul 2017 [edited]
http://www.who.int/emergencies/mers-cov/risk-assessment-july-2017.pdf

Summary:
Between 2012 and Fri 21 Jul 2017, 2040 laboratory-confirmed cases of Middle East respiratory syndrome-coronavirus (MERS-CoV) infection were reported to WHO, 82 percent of whom were reported by the Kingdom of Saudi Arabia (Figure 1 [see source URL]). In total, cases have been reported from 27 countries in the Middle East, North Africa, Europe, the United States of America, and Asia (Table 1). Males above the age of 60 with underlying conditions, such as diabetes, hypertension and renal failure, are at a higher risk of severe disease, including death. To date, at least 710 individuals have died (crude CFR 34.8 percent).

Since the last global update published on [5 Dec 2016], 199 laboratory-confirmed cases of MERS-CoV from 4 countries were reported to WHO (190 from Saudi Arabia, 3 from Qatar, 4 from the United Arab Emirates, 1 from Lebanon and 1 from Oman), of whom 58 (29.2 percent) have died. Among these cases, 72.9 percent were male and the median age was 54-years-old (IQR 39-65). At the time of writing, 59 of 199 (29.6 percent) patients were reported as asymptomatic or having mild disease and 80 (40.2 percent) had severe disease and/or died. At least one underlying condition was reported in 114 cases (57.3 percent) since the last update, including chronic renal failure (11.4 percent), heart disease (12.3 percent), diabetes mellitus (71.0 percent), and hypertension (67.5 percent). One pregnant woman was also reported and, at the time of writing, had lost her baby and was on mechanical ventilation in an ICU.

Overall, the epidemiology, transmission patterns, clinical presentation of MERS patients and viral characteristics reported since the last update are consistent with past patterns described in previous WHO risk assessments: MERS-CoV is a zoonotic virus that has repeatedly entered the human population via direct or indirect contact with infected dromedary camels in the Arabian Peninsula. Limited, non-sustained human-to-human transmission in health-care settings continue to occur, primarily in the Kingdom of Saudi Arabia, due to the non-specificity of MERS symptoms resulting in late diagnosis of MERS. The risk of exported cases to areas outside of the Middle East due to travel remains significant.

While there have been significant improvements in surveillance for MERS, especially in the Kingdom of Saudi Arabia, and in reacting to suspect clusters, early identification in the community and in health-care systems, compliance with the infection prevention and control measures and contact follow up remain major challenges for MERS outbreak prevention and control.

The continued importance of MERS-CoV in healthcare-settings:
Since the last global update of [5 Dec 2016], approximately 31 percent of cases reported to WHO were associated with transmission in a health-care facility. These cases included health-care workers (40 cases), patients sharing rooms/wards with MERS patients, or family visitors.

Though not unexpected, these transmission events continue to be deeply concerning, given that MERS-CoV is still a relatively rare disease about which medical personnel in health-care facilities have low awareness. Globally, awareness for MERS-CoV is low and, because symptoms of MERS-CoV infection are non-specific, initial cases are sometimes easily missed. With improved compliance in infection prevention and control, namely adherence to the standard precautions at all times, human-to-human transmission in health-care facilities can be reduced and possibly eliminated with additional use of transmission-based precautions.

Since the last update, several health-care-associated MERS outbreaks have occurred, including the following:

- An outbreak of MERS occurred in a hospital in Riyadh City, Riyadh in June 2017. From [1 Jun-3 Jul 2017], 34 laboratory-confirmed cases were reported to WHO. The initial case was a 47-year-old male who required emergency intubation in the emergency department, prior to identification of being infected with MERS-CoV. Prior to diagnosis, more than 220 health-care workers, patients and visitor contacts were identified for follow-up from contact with this patient. Extensive contact tracing, follow-up and laboratory testing identified an additional 33 cases during this outbreak. Overall, the cases associated with this outbreak had a median age of 34.5-years-old (IQR 30-54), are predominantly male (58.8 percent) and half were health care workers (50.0 percent). Eleven patients were classified as having severe disease, of whom 7 died, and 22 were asymptomatic.

- One case from the cluster described above also sought treatment (renal dialysis) at a 2nd health-care facility in Riyadh City, Riyadh in June 2017. Within this healthcare facility, 5 additional cases were identified. Transmission occurred among 3 household contacts, one patient contact in the hospital, and one health-care worker contact.

- Also in June 2017, an unrelated MERS cluster occurred in a hospital in Riyadh City, Riyadh. This cluster involved 9 cases: the 1st case who reported direct contact to dromedary camels (occupational exposure as a butcher) and 8 health-care worker contacts (4 were reported as asymptomatic and 4 reported mild disease).

In March and April 2017, 2 unlinked clusters of MERS occurred at the same hospital in Wadi Aldwaser city, Riyadh Region.

- A cluster of MERS occurred in March 2017. This cluster included 10 laboratory-confirmed patients, 40 percent of whom were male, 20 percent of whom were health-care workers and 40 percent of whom were reported as asymptomatic. The source of infection in the initially-identified patient was under investigation and transmission occurred in a renal dialysis unit within this hospital and between household contacts.

- A cluster of MERS occurred in April 2017. This cluster involved 5 laboratory-confirmed cases: the initial case, 3 household contacts and one health-care worker.

The apparent increase in the number of asymptomatic contacts identified in health-care settings are being identified due to a policy change by the Ministry of Health of the Kingdom of Saudi Arabia, in which all high-risk contacts are tested for MERS-CoV regardless of the development of symptoms.

Drivers of transmission and the exact modes of transmission in health-care settings have not been articulated and are currently the focus of collaborative scientific research. From observational studies, transmission in health-care settings is believed to have occurred before adequate infection prevention and control procedures were applied and cases were isolated. Investigations at the time of the outbreaks indicate that aerosolizing procedures conducted in crowded emergency departments or medical wards with sub-optimal infection prevention and control measures in place resulted in human-to-human transmission and environmental contamination.

Community-acquired cases and reported links to dromedary camels:
Since the last update, 56 human cases are believed to have been infected in the community. Of these 56 reported cases, 47 (89.9 percent) reported direct or indirect contact with dromedaries in Saudi Arabia (45 cases), Qatar (1 case) and the United Arab Emirates (1 case).

Improvement in multi-sectoral investigation of community-acquired cases is evident, including testing of dromedary animals/herds in the vicinity of community-acquired cases and follow-up of human contacts of laboratory-confirmed cases. The Ministries of Health in affected countries notify the Ministries of Agriculture when human cases report a link with animals. Investigations in animals are carried out by officials from the Ministries of Agriculture and results, if positive for MERS-CoV, are reported to OIE.

Exported cases identified outside the Middle East:
Since the last update, no cases have been reported outside of the Middle East.

Summary - information available from 2012 to date:
Thus far, no sustained human-to-human transmission has occurred anywhere in the world, however limited no sustained human-to-human transmission in health-care facilities remains a prominent feature of this virus. WHO continues to work with health authorities in the affected countries. WHO understands that health authorities in affected countries, especially those in the most affected countries, are aggressively investigating cases and contacts, including testing for MERS-CoV among asymptomatic contacts, and applying mitigation measures to stop human-to-human transmission in health-care settings.

Of all laboratory-confirmed cases reported to date (n=2040), the median age is 52 (IQR 36-65; range >1-109-years-old) and 66.4 percent are male.

At the time of reporting, 21.5 percent of the 2040 cases were reported to have no or mild symptoms, while 46.8 percent had severe disease or died. Overall, 19.6 percent of the cases reported to date have been in health-care workers.

Since 2012, 27 countries have reported cases of MERS-CoV infection. In the Middle East: Bahrain, Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, the Kingdom of Saudi Arabia, the United Arab Emirates and Yemen; in Africa: Algeria and Tunisia; in Europe: Austria, France, Germany, Greece, Italy, the Netherlands, Turkey and the United Kingdom; in Asia: China, the Republic of Korea, Malaysia, the Philippines and Thailand; and in the Americas: the United States of America (Table 1 [see source URL]).

The majority of cases (approximately 82 percent) have been reported from Saudi Arabia (Figure 1 [see source URL]).

Populations in close contact with dromedaries (e.g. farmers, abattoir workers, shepherds, dromedary owners) and healthcare workers caring for MERS-CoV patients are believed to be at higher risk of infection. Healthy adults tend to have mild subclinical or asymptomatic infections. To date, limited human-to-human transmission has occurred between close contacts of confirmed cases in household settings.

More efficient human-to-human transmission occurs in health-care settings due to inadequate and/or incomplete compliance with the infection prevention and control measures and delay in triage or isolation of suspected MERS patients.

Health-care-associated transmission has been documented in several countries between 2012-2016, including the Kingdom of Saudi Arabia, Jordan, the United Arab Emirates, France, the United Kingdom, and the Republic of Korea with varying outbreak sizes (2-180 reported cases per outbreak).

The largest outbreak outside of the Middle East occurred in the Republic of Korea resulting in 186 cases (including one case who travelled to China) and 38 deaths.

Overall, the reproduction number (R0) of MERS-CoV is <1 with significant heterogeneity in specific contexts. Specifically, outbreaks in health-care settings can have R>1, but they can be brought under control (R<1) with proper application of infection prevention and control measures and early isolation of subsequent cases.

--
Communicated by:
ProMED-mail

[The above report is a very helpful up-to-date presentation of the current global picture with MERS-CoV and what is known to date on the epidemiology. For those who wish to see the graphics and tables they can be found at the source URL link provided above.

The walk away messages can be summarized as:
- 82 percent of reported cases are from Saudi Arabia.
- males predominate in case genders
- high risk pre-existing co-morbidities include diabetes mellitus, hypertension, heart disease and chronic renal failure (in descending order of magnitude)
- dromedary camel exposure still an observed high risk exposure
- healthcare facility exposure still a major high risk exposure
- human-to-human transmission still limited transmission chains
- infection control measures still sub-optimal
- delayed diagnosis (sub-optimal healthcare worker suspicion)
- healthcare workers still an observed high risk group

So questions that still remain after reading the assessment:
- Why does Saudi Arabia have the overwhelming share of reported cases?
- Is this related to different animal husbandry practices from other countries with large camel populations?
- Why are there still deficiencies in the healthcare environment?
- Could this be related to high turnover of healthcare workers? - Mod.MPP]

See Also
MERS-CoV (47): Saudi Arabia (MK)
MERS-CoV (46): Saudi Arabia, WHO 20170707.5158219
MERS-CoV (45): Saudi Arabia (HA), Lebanon ex Saudi Arabia, WHO 20170705.5153627
MERS-CoV (44): Lebanon ex Saudi Arabia, Saudi Arabia, exp. antiviral, RFI 20170701.5144892
MERS-CoV (43): Saudi Arabia, WHO 20170628.5137634
MERS-CoV (42): Saudi Arabia (RI, SH, MD), WHO 20170628.5136101
MERS-CoV (41): Saudi Arabia (RI, SH) 20170620.5117143
MERS-CoV (40): animal reservoir, camels, review, FAO 20170619.5115999
MERS-CoV (30): Saudi Arabia (RI,MD,MK) 20170602.5077920
MERS-CoV (20): Qatar, Saudi Arabia, WHO 20170404.4947466
MERS-CoV (10): Saudi Arabia (SH, MK) 20170202.4811346
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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