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Khalid H. Alanazi et al
Table 3. Exposure to Known MERS Cases and Reported PPE Use Among interviewed HCP Cases who Reported Contact with a Confirmed MERS Case (N=16), Hospitals A&B
Hospital A
Variable Exposure
Within 1.5 m of a confirmed case around the time they were positive for >10 min
In the same room during aerosolizing procedures
Reported PPE use during exposure N95 respirator or PAPR Faceshield or goggles Surgical mask Gloves Gown
Before Patient Isolation (n=9), No. (%)a
9 (100) 4 (44)
0 0
4 (44) 6 (67) 4 (44)
During Patient Isolation (n=0), No. (%)b
0 0
0 0 0 0 0
Hospital B
Before Patient Isolation (n=3), No. (%)
3 (100) 0
1 (33) 0
1 (33) 1 (33) 0
During Patient Isolation (n=4), No. (%)
4 (100) 3 (75)
4 (100) 3 (75) 0
4 (100) 4 (100)
Note. MERS, Middle East respiratory syndrome; PPE, personal protective equipment; HCP, healthcare personnel. aOne HCP denied any contact with a confirmed case when interviewed, reported only contact with a non-MERS case patient on Ward A and was excluded from this table. bNo transmission at hospital A was associated with exposure during isolation.
isolation, and 4 reported contact following implementation of IPC measures for MERS-CoV in a negative-pressure room. Of these latter 4, 3 participated in aerosolizing procedures, including intubation, open suctioning of airways, and/or cardiopulmonary resuscitation. All 3 reported wearing full PPE, including gloves, gown, N95 mask, and face shield. Also, of these 4 HCP, 2 reported visible contamination of gloves or gown by bodily fluids during care of index patient B, who was reported to have had copious respiratory secretions. No transmission to patients or visitors at hospital B was identified. Of the 9 HCP cases, 7 were interviewed and had serum col-
lected; all 7 reported close, prolonged contact with index patient B. Time from symptom onset to serum collection was 39–47 days. Among these 7 HCP, 3 were seropositive, and 2 had an inde- terminate result. Among the 3 seropositive HCPs, 2 had been diagnosed with pneumonia, 1 of whom also had diabetes mellitus. The third reported productive cough, dyspnea, and diabetes mellitus. Among the 2 with an indeterminate result, 1 reported rhinorrhea and nonproductive cough, and the other had fever and upper respiratory tract and gastrointestinal symptoms; neither had comorbidities. The 2 seronegative HCP-cases reported mild upper-respiratory-tract symptoms; 1 also had fever and gastro- intestinal symptoms. All 9 survived, and none were critically ill. At hospital B, 34 of 50 MERS-CoV rRT-PCR–negative HCP
contacts of cases (68%) were interviewed and provided serum. One was seropositive, a physician who had close, prolonged contact with index B after isolation and while wearing recom- mended PPE; however, he had previously tested rRT-PCR posi- tive for MERS-CoV in 2013. Of 9 HCP cases identified at hospital B, 2 tested positive by
rRT-PCR on their first test, 5 tested negative then subsequently tested positive, and 2 had an initial indeterminate rRT-PCR test result (Fig. 3). One HCP case with an initial indeterminate result was subsequently confirmed by rRT-PCR, the other was con- firmed by genome sequencing. For the 8 HCP cases with a positive rRT-PCR test, the median time from known exposure to positive sample collection was 6.5 days (range, 2–10 days).
Discussion
A large MERS-CoV transmission event occurred in Riyadh dur- ing May–June 2017, with cases initially reported from 2 hospitals. Our molecular and epidemiologic investigation demonstrated separate virus introductions at the 2 facilities, each by a single index case. Similar to previous outbreaks,3,21,22 transmission was characterized by early superspreading events, which led to a rapidly escalating number of cases. During these 2 outbreaks, delays in the recognition and
isolation of early cases, along with emergency intubation (sometimes precluding recommended airborne precautions), were associated with superspreading events. Cases linked to superspreading events included 2 index cases and 2 secondarily infected hospitalized cases; all had severe illness, low cycle threshold values suggesting high viral loads, and all 4 died. These results are consistent with prior evidence that length of patient hospitalization before isolation and high viral loads have been linked to transmission.23 Although 2 of the cases asso- ciated with superspreading events were contacts of index A, they were not detected via contract tracing before developing symptoms and were associated with additional healthcare- associated transmission. The delay in recognition of index patient A due to the
patient’s comorbidities and complex presentation has been previously described.24 This case patient was admitted to the ED without respiratory precautions despite initial triage, highlighting the need for strengthening triage practices. The presentation of index patient B before hospitalization is nota- ble; this 23-year-old male had no known comorbidities and initially presented to clinic C with a mild illness, followed by further visits with worsening respiratory symptoms. Further- more, 2 physicians at clinic C tested seropositive after an indeterminate rRT-PCR test, suggesting transmission at clinic C. Thus, increased testing for MERS-CoV in an outpatient setting for individuals with known risk factors and worsening respiratory symptoms might facilitate early recognition of MERS cases.
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