MERS CoV Outbreak Riyadh, July-Aug 2015

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1 MERS CoV Outbreak Riyadh, July-Aug 2015

2 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 a worldwide outbreak with over 8000 confirmed cases including 774 deaths

3 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

4 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

5 King Abdulaziz Medical City 1000 Bed University Teaching Hospital Emergency Department 150 beds 250,000 visits per year 7 ICUs approx 80 beds

6 693 deaths Mid June Mid September 2015 King Abdulaziz Medical City, Riyadh 130 Cases

7 MERS cases June to Sept cases Patients n=87 Mean age 64 Saudi 94% Male 64% Chronic Comorbidity 99% Mean number comorbidities 5.6 Healthcare workers n=43 (3000 screened, 86% of cases asymptomatic) Mean Age 40 Female 77% Philippines 74% Chronic Comorbidity 42% Mean number comorbidities 2

8 Location at time of MERS infection

9 ICU admissions with MERS Patients (n=87) mortality 59% HCW (n=43) no deaths Admitted ICU n=55 Ventilated 96% Mean Ventilator days 11 ICU mortality 93% Admitted ICU n=8 Ventilated n=7 Mean Ventilator days 15 ECMO n=1 (72% of HCW were never admitted to hospital)

11 How to Identify a potential MERS Case During a MERS Outbreak Any patient with acute respiratory deterioration after admission is MERS until otherwise proven otherwise Saudi Arabia not during a MERS Outbreak any patient with a cough, fever and/or respiratory distress Definitely MERS if: 1) pyrexia with low WCC & 2) deteriorating renal function despite CVS stability

12 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?

13 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

14 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

15 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

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

17 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

18 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 in the emergency room

19 WHO Urgent Mission for the investigation of the outbreak of the MERS in South Korea Super-spreading events of MERS-CoV infection predisposing factors: 1 failure to implement strict isolation of patients 2 poor communication 3 Overcrowding in ER 3 inadequate ventilation 4 limited availability of isolation rooms in ER

20 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

21 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.

22 Problems with the MERS CoV test The 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

23 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

24 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

25 Failure to close ER ER finally emptied of patients On 22 nd of August

26 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?

27 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

28 What is happening in Riyadh to prevent further outbreaks? SARI Clinic All respiratory symptoms screening pre ER Special Respiratory Clinic Droplet isolation

30 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?

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

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

35 Typical A&E Admission Respiratory Failure A&E Initial Resuscitation High Flow 02, Suctioning, NIV, Nebulisers, Physio Intubation & Ventilation Highest risk of Spreading infection Differential diagnosis Risk assessment ICU PPE PPE

36 Typical A&E Admission Respiratory Failure Treat as SARI PPE for SARI Droplet protection A&E Initial Resucitation High Flow 02, Suctioning, NIV, Nebulisers, Intubation & Ventilation PPE Differential diagnosis ICU Risk assessment Reassess need & type of PPE

38 The risks are out there

39 Any Questions?

Middle East Respiratory Syndrome Coronavirus

GUIDE TO INFECTION CONTROL IN THE HOSPITAL CHAPTER 54 Middle East Respiratory Syndrome Coronavirus Author Ziad.A. Memish, MD, FRCPC, FACP Chapter Editor Michael Stevens, MD, MPH Topic Outline Topic outline