82 May June


26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 101112131415161718 FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN


7 23 A


12 13


9 8


6


2 3 4


5 36 26 15 28 33


34 35


37 Magenta – Exposed in Ambulance


10 11


40 41


42 B 43 44 45


47 46


48


Fig. 2. Transmission of MERS-CoV infections between cases at hospital A, an outpatient dialysis unit, and hospital B, Riyadh, Saudi Arabia, from May 28 through June 19, 2017. Cases are shown by date of symptom onset or positive real-time RT-PCR test, except index cases, which are shown by date of hospitalization.


related to several humanMERS-CoV sampled from Riyadh in 2016 (KX154684, MG011362, KX154693) (Fig. 4).


Hospital A


Among 38 cases linked to hospital A, 17 were patient cases, 17 were HCP cases, and 4 were family members (Table 1). Index patient A was a 46-year-old factory worker with no history of contact with camels or camel products. He presented to the ED on May 28 with cough, shortness of breath, and chest pain. Although ER triage was in place, the patient was not initially considered a suspected MERS case, and he remained in the ED for


>14 hours prior to transfer to a medical ward (ward A). Index patient A was directly linked to 19 subsequent cases: 1 ambulance driver exposed in the ambulance, 13 likely exposed in the ED, and 5 on ward A, where index A was intubated without airborne precautions in place. On hospital day 3, index patient A was suspected of MERS and was transferred from ward A to a negative-pressure room with recommended isolation precautions. Index patient A was confirmed rRT-PCR positive for MERS-CoV on May 31, and contact tracing began the same day. All secondary transmission at hospital A likely occurred before suspicion of MERS in individual cases and the subsequent implementation of recommended transmission-based precautions.


14 16 18 20 21


17 27 32 38


Purple – Exposed in Inpatient Dialysis Unit


Brown – Family member/Visitor Pink – Exposed in Outpatient


Dialysis Unit Hospital B


Light Green – Exposed in ICU Light Blue – Exposed in ED


31 24 19 22 25


29 30


Key


Hatched fill – Healthcare worker Solid fill – Patient Red outline – Died


Black outline – Recovered Orange – Index case


Solid line – likely transmission route


Dashed line – possible but unlikely Transmission route


Hospital A


Green – Exposed in Ward A Yellow – Exposed in Ward B Blue – Exposed in ED


Khalid H. Alanazi et al


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