Infection Control & Hospital Epidemiology (2019), 40,79–88 doi:10.1017/ice.2018.290
Original Article
Scope and extent of healthcare-associated Middle East respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in Riyadh, Saudi Arabia, 2017
Khalid H. Alanazi MD, MPH1,a, Marie E. Killerby VetMB, MPH2,3,a, Holly M. Biggs MD, MPH2, Glen R. Abedi MPH2, Hani Jokhdar MBBS, MSc, PhD1, Ali A. Alsharef MD1, Mutaz Mohammed MBBS, MPH1, Osman Abdalla1, Aref Almari PhD1, Samar Bereagesh1, Sameh Tawfik MD1, Husain Alresheedi MSN, DIPC1, Raafat F. Alhakeem MD1, Ahmed Hakawi MD1, Haitham Alfalah MD3, Hala Amer MD, MPH, PhD, CIC3,4, Natalie J. Thornburg PhD2, Azaibi Tamin PhD2, Suvang Trivedi MS5, Suxiang Tong PhD2, Xiaoyan Lu MS2, Krista Queen PhD2, Yan Li MS2, Senthilkumar K. Sakthivel PhD2, Ying Tao PhD2, Jing Zhang PhD2, Clinton R. Paden PhD2, Hail M. Al-Abdely MD1,
Abdullah M. Assiri MD1, Susan I. Gerber MD2 and John T. Watson MD2 1Ministry of Health, Riyadh, Saudi Arabia, 2Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States, 3King Saud Medical City, Riyadh, Saudi Arabia, 4Department of Community Medicine, National Research Center, Cairo, Egypt, 5IHRC, contractor to National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States and 6Batelle, contractor to National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
Abstract
Objective: To investigate a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak event involving multiple healthcare facilities in Riyadh, Saudi Arabia; to characterize transmission; and to explore infection control implications. Design: Outbreak investigation. Setting: Cases presented in 4 healthcare facilities in Riyadh, Saudi Arabia: a tertiary-care hospital, a specialty pulmonary hospital, an outpatient clinic, and an outpatient dialysis unit. Methods: Contact tracing and testing were performed following reports of cases at 2 hospitals. Laboratory results were confirmed by real- time reverse transcription polymerase chain reaction (rRT-PCR) and/or genome sequencing. We assessed exposures and determined seropositivity among available healthcare personnel (HCP) cases and HCP contacts of cases. Results: In total, 48 cases were identified, involving patients, HCP, and family members across 2 hospitals, an outpatient clinic, and a dialysis clinic. At each hospital, transmission was linked to a unique index case. Moreover, 4 cases were associated with superspreading events (any interaction where a case patient transmitted to ≥5 subsequent case patients). All 4 of these patients were severely ill, were initially not recognized as MERS-CoV cases, and subsequently died. Genomic sequences clustered separately, suggesting 2 distinct outbreaks. Overall, 4 (24%) of 17 HCP cases and 3 (3%) of 114 HCP contacts of cases were seropositive. Conclusions: We describe 2 distinct healthcare-associated outbreaks, each initiated by a unique index case and characterized by multiple superspreading events. Delays in recognition and in subsequent implementation of control measures contributed to secondary transmission. Prompt contact tracing, repeated testing, HCP furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission.
(Received 16 July 2018; accepted 16 October 2018)
Author for correspondence: Marie E. Killerby, Division of Viral Diseases, National
Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA. E-mail:
lxo9@cdc.gov PREVIOUS PRESENTATION: Data from this study were presented at the Interna- tional Conference on Emerging Infectious Diseases (ICEID) on August 29, 2018, in
Atlanta, Georgia. a Authors of equal contribution.
Cite this article: Alanazi KH, et al. (2019). Scope and extent of healthcare-associated
Middle East respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in Riyadh, Saudi Arabia, 2017. Infection Control & Hospital Epidemiology 2019, 40, 79–88. doi: 10.1017/ice.2018.290
Middle East respiratory syndrome coronavirus(MERS-CoV)isa novel β-coronavirus identified in 2012.1 Infectionmay result in upper or lower respiratory tract illness, with symptoms ranging from inapparent or mild to rapidly progressive respiratory failure and, in ~35% of confirmed cases, death.2 Numerous large, healthcare- associated outbreaks of MERS-CoV have occurred, resulting in transmission to patients, visitors, and healthcare personnel (HCP).3–6 Prevention of MERS-CoV transmission in healthcare settings requires effective triaging and a high clinical index of suspicion to
This work is classified, for copyright purposes, as a work of the U.S. Government and is not subject to copyright protection within the United States.
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