








key: cord-291650-1qy6y7f0
authors: Butt, Taimur S.; Koutlakis-Barron, Irene; AlJumaah, Suliman; AlThawadi, Sahar; AlMofada, Saleh
title: Infection control and prevention practices implemented to reduce transmission risk of Middle East respiratory syndrome-coronavirus in a tertiary care institution in Saudi Arabia
date: 2016-05-01
journal: Am J Infect Control
DOI: 10.1016/j.ajic.2016.01.004
sha: 
doc_id: 291650
cord_uid: 1qy6y7f0

BACKGROUND: Transmission of Middle East respiratory syndrome-coronavirus (MERS-CoV) among health care workers (HCWs) and patients has been documented with mortality rate approximating 36%. We propose advanced infection control measures (A-IC) used in conjunction with basic infection control measures (B-IC) help reduce pathogen transmission. B-IC include standard and transmission-based precautions. A-IC are initiatives implemented within our center to enhance effectiveness of B-IC. OBJECTIVE: Study effectiveness of combining B-IC and A-IC to prevent transmission of MERS-CoV to HCWs. METHODS: A retrospective observational study was undertaken. A-IC measures include administrative support with daily rounds; infection control risk assessment; timely screening, isolation, and specimen analysis; collaboration; epidemic planning; stockpiling; implementation of contingency plans; full personal protective equipment use for advanced airway management; use of a real-time electronic isolation flagging system; infection prevention and control team on-call protocols; pretransfer MERS-CoV testing; and education. RESULTS: A total of 874 real-time polymerase chain reaction MERS-CoV tests were performed during the period beginning July 1, 2013, and ending January 31, 2015. Six hundred ninety-four non-HCWs were tested, of these 16 tested positive for MERS-CoV and their infection was community acquired. Sixty-nine percent of the confirmed MERS-CoV-positive cases were men, with an average age of 56 years (range, 19-84 years). Of the total tested for MERS-CoV, 180 individuals were HCWs with zero positivity. CONCLUSIONS: Adhering to a combination of B-IC and A-IC reduces the risk of MERS-CoV transmission to HCWs.

Transmission of Middle East respiratory syndrome-coronavirus (MERS-CoV) among health care workers (HCWs) and patients in hospitals within Saudi Arabia has been documented. 1 Of the HCWs who have acquired this infection, more than 63% acquired the infection within Saudi Arabia, where the majority of MERS-CoV cases have been reported. 2 As of June 20, 2015, 1,338 cases have occurred worldwide, and of these 77.5% (n = 1,038) were identified within Saudi Arabia. 3, 4 The main contributing factor for health care-associated transmission and causality of outbreaks among Saudi hospitals is due to emergency department (ED) overcrowding and poor ventilation. 5 In turn, this can be a reflection of institutional overcrowding, inpatient bed occupancy reaching or exceeding full capacity, and/or a lack of compliance to and understanding of the importance of implementing infection control and prevention (ICP) measures. This belief is supported by internationally recognized agencies, including the World Health Organization (WHO) and the US Centers for Disease Control and Prevention. The organizations support the practice of adhering to ICP measures. Basic infection control measures (B-IC), defined as standard and transmissionbased precautions, play a major role in preventing and controlling pathogen spread, including adherence to hand hygiene, environment and equipment cleanliness, use of personal protective equipment (PPE) such as high-efficiency particulate respirators (eg, N-95 or R-95), and adhering to respiratory/cough etiquette. 6 We propose that the spread of MERS-CoV among HCWs is preventable when B-IC are used in combination with institution-specific advanced infection control measures (A-IC). In this article, A-IC implemented in a tertiary care hospital during a time of epidemic is described.

During the initial and intermediate period after discovering this novel virus during June 2012 it was noted that symptoms and complexity of patients presenting with infection were variable. 7 This resulted in a case definition that required modification over time to allow for broader screening of patients with flu-like illness. The initial case definition mainly encouraged screening of patients with severe acute respiratory illness requiring intensive care unit (ICU) admission. 3 In the authors' experience, in dealing with MERS-CoV cases in the early stages of disease recognition there were poorly established systems in place for identification of suspected/confirmed cases. We believe that this was due to an unclear incubation period, poor rapid implementation of isolation precautions and use of PPE, and the unavailability of diagnostic testing among regional health care facilities. These health care facilities relied on an inconsistent availability of appropriate packaging and transportation of specimens to approved Ministry of Health (MOH) reference laboratories for testing of samples. Consequently, there were delays in communication and appropriate isolation of positive cases resulting in spread of infection to HCWs. 1

B-IC are well-recognized preventative measures considered the minimum requirement for infection prevention and control. 6, 8 A-IC are institution-specific measures that enhance B-IC to further reduce the risk of transmission.

B-IC are based on key components of standard precautions and recommended transmission-based precautions for prevention and control of transmissible diseases. This includes appropriate hand hygiene practices; proper cleaning of the environment and equipment; prompt initiation of transmission-based precautions for suspected/confirmed cases until noninfectious; segregation of confirmed/suspected cases in waiting areas; use of single hospital patient rooms; and proper availability, quality, type, and use of PPE 6,9 (Table 1) .

A-IC is a group of institution-specific measures that go above and beyond B-IC and enhance their effectiveness. It is vital that administrative support is sought to approve and fund the necessary initiatives. The following outlines the A-IC measures adopted at our institution (Table 1). 1. Interdepartmental collaborative meetings: As part of the established institutional epidemic plan, using both interdepartmental collaboration and institutional expertise, daily morning meetings are held. These meetings are undertaken at a time of high incidence within the community, other regional institutions, or when an alert has been issued by the MOH. Key members include hospital administration, senior staff from the infectious diseases department, ICP, ED, ICU, nursing, microbiology, case management, and others as deemed necessary. Their objective is to assess, monitor, and recommend risk mitigation strategies. Current regional and international information regarding MERS-CoV disease activity, institutional preparedness, and its capabilities are discussed. During these meetings initiatives are formulated, implemented if applicable, and evaluated for success and/or modification. Measures to reduce risks referred to in this article as A-IC were discussed in these meetings and implemented institution-wide.

wide infection control risk assessment to address areas of concern was undertaken. Areas of deficiencies addressed at the organization level include insufficient number of staff in highrisk areas, fit testing for high-efficiency particulate respirators (especially for ED, ICU, and direct patient care providers), overcrowding in the ED, ventilation systems in the ED, extended turnaround time of MERS-CoV test results, and awareness of the importance of early identification and isolation of suspected cases. With each automated telephone text message reminder of upcoming clinic or admission came an additional reminder to inform staff of any flu-like illness upon arrival. This is in conjunction with a prescreening process established in the ED and clinic receptions.

implemented as an extension of the existing institutional epidemic plan ( e. Patient transportation: Isolation transportation pods were purchased to be used for transportation of any patient suspected or confirmed positive for an airborne infectious disease, including MERS-CoV.

During epidemic plan activation a disease-specific education campaign is implemented. Posters, pamphlets, and the intrahospital television system are used for communication (Fig 2) . 14. Staff Education and Communication: Staff preparation training and specific education to care for patients with/suspected MERS-CoV was undertaken. 15. Transparency: While maintaining confidentiality, transparency is important to enhance dissemination of accurate information to all staff. This can create an atmosphere of trust, loyalty, and support; therefore, HCWs are more likely to adhere to recommendations and reduce their absenteeism.

Method ICIS was used to retrieve patient and HCW data. For the purpose of this observational study, data were retrieved retrospectively and collected for a continuous period of 19 months. Those tested for MERS-CoV included patients with suspected/confirmed cases who met the case definition and/or HCWs who were tested during an outbreak investigation for protected/unprotected exposure. Duplicate tests were removed if testing was performed during the same episode of illness or exposure. All patient and HCW confidentiality and rights were maintained. Microsoft Office (Redmond, WA) and Visio (Microsoft, Redmond, WA) were used to plot results and Research Advisory Committee approval (RAC# 2151-194) was obtained to use the data for this publication.

A total of 874 cases were tested for MERS-CoV from the period beginning July 1, 2013, and ending January 31, 2015. Of these, 16 (1.8%) were MERS-CoV positive. They were all non-HCWs (Fig 3) . During this time period the ED served more than 80,000 patients and institutional inpatient bed capacity was >700 with an occupancy rate consistently >90%. Institution employee numbers exceeded 11,000.

Of the 874 MERS-CoV samples tested, 180 (21%) were from HCWs. HCW testing was due to meeting the case criteria or to protected/ unprotected exposure. Exposure occurred in 3 of the confirmed cases as a result of a delay in the initiation of isolation precautions due to lack of early recognition of symptoms or incubation period. Testing of the non-HCWs (n = 694) was due to case criteria being met during admission or upon presentation to the institution through the ED or clinics, or as part of a screening requirement at the time of admission; that is, direct admission from another hospital per the epidemic plan.

The majority of patients with positive cases were men (69%) with a mean age of 56 years (range, 19-84 years). All case patients except 1 had comorbidities and/or immunocompromised status. Ten of the 16 patients with confirmed cases died (62%). Mortality was directly or indirectly attributed to complications that developed as a result of MERS-CoV infection. All case patients had respiratory symptoms on initial presentation except for 1 patient who was admitted for elective surgery and developed respiratory symptoms with fever postoperatively on day 7. This was considered community acquired because the incubation period overlapped with the preadmission period. No cases were considered health careassociated infections (Table 3) .

Potential HCW exposure days are calculated from the date of MERS-CoV symptom onset while in hospital until either the date of negative screening result(s) or death while positive. During the period of study the potential HCW exposure days totaled 338. The mean duration of potential infectivity per case was 21 days (range, 4-57 days).

Due to the nature of their work, HCWs remain at high risk of acquiring communicable diseases from occupational exposure. Experience and data collected during the severe acute respiratory syndrome epidemic in Hong Kong suggests an infection rate of 22% among HCWs. 11 During April-August 2014 a number of hospital outbreaks were reported within Saudi Arabia increasing the risk of HCW exposure. This risk to HCWs is supported by ongoing findings reported by the WHO. The MERS-CoV Situation Update Report-15 June 2015 12 states that 10%-29% of the total MERS-COV cases identified in Saudi Arabia were in HCWs. Front-line HCWs caring for undifferentiated and severely ill patients who do not adhere to ICP measures are at the highest risk. 10 Upon the discovery of the novel coronavirus and in anticipation of a local and regional threat, a taskforce was formed to evaluate our institution's readiness to deal with the developing situation and to initiate proactive measures to protect staff, patients, and visitors. This taskforce included representatives from experts from the infectious disease department (adult and pediatric), ICP, ED, laboratory, nursing, research, supply chain, and other relevant stakeholders. This article reflects the work undertaken by the taskforce members who recommended and implemented measures to mitigate the risk of viral spread.

Although institutions aim to protect and safeguard their HCWs against communicable diseases, success is not always attainable without a culture of vigilance. The approval by executive management to implement the recommended ICP measures was primarily due to recognition of a true potential threat, and in support of recommendations by the taskforce. This prompt action and support is reflective of the mission, vision, and core values of our institution, which supports a culture of safety. Due to urgency, time for a prescheduled mock drill to test proposed interventions and make the necessary adjustments based on the results of the simulation was not possible at time of initial implementation. Changes or improvements to ICP measures occurred in real time with immediate effect. Ongoing monitoring for effectiveness occurred through observational HCW compliance monitoring, noting frequency of unprotected exposure events, and screening during outbreak investigations. Those working in our institution-especially within high-risk areas (eg, ED and ICU) observed an increased level of anxiety reflected by an increased use of masks while not performing direct patient care. In particular, in the use of high-particulate respirators. In our opinion this anxiety was as a result of rumors and misconceptions of MERS-CoV transmission and number of actual cases within our institution, documented human-to-human and animal-to-human transmission, a high mortality rate (36%) that includes HCWs, limited treatment options, and the unavailability of vaccines. 4 Communication and transparency helped to reduce levels of anxiety and rumor. Our reported MERS-CoV mortality rate of 62% is higher than that reported nationally and most likely due to the complexity and comorbidities of the patient population served in our major city tertiary care institution.

There were 16 confirmed MERS-CoV cases over a 2-year period with a collective potential infectivity duration of 338 days. None of the confirmed cases were health care-associated infections or HCWs from this institution. As reflected in Table 3 , cases identified in 2013 from date of admission to date of first MERS-CoV sample took longer than what was observed in subsequent years. This reflects the successful work of the taskforce. B-IC were already in place but required reinforcement. Standard and transmission-based precautions, and hand hygiene are ICP key performance indicators for continual compliance monitoring and reporting. 13, 14 A-IC were introduced and reinforced to support the B-IC measures. Many of the A-IC measures implemented during this period have now become standard-of-care practices within the institution. Without administrative and leadership support, targeted resource allocation, and high HCW compliance rates, ICP measures would not be effective. This includes timely information dissemination, investment by the institution on education, ongoing awareness and staff development, adequate and high-quality supplies, and meticulous screening processes. Clear and open communication channels are vital between all parties and are a prerequisite for success.

Close contact with the MOH was maintained both in reporting of cases and receiving directives for case identification and management. In addition, updates posted by the WHO and Centers for Disease Control and Prevention were reviewed on a daily basis to remain current and monitor for changes to guidelines, and in the understanding of the disease processes. Adjustments were made ac-cordingly to institutional case definitions, management guidelines, and ICP measures. No outside consultation was undertaken to develop and refine the A-IC measures.

This was a single-center study; therefore, results may not be generalized to other institutions. The actual level of compliance and benefits of implemented ICP measures were not systematically measured because a randomized control study would be unethical. Seroconversion rates for MERS-CoV were not undertaken among HCWs because this test is currently unavailable within our institution.

Our institution successfully reduced the transmission risk of MERS-CoV among HCWs and patients. We believe that our success is multifactorial, including a proactive and visionary response by leadership, collaborative efforts by all departments, and staff adherence to both B-IC and A-IC measures. We suggest that other institutions under similar circumstances conduct an internal review as soon as possible and implement appropriate measures accordingly. To our knowledge, a similar experience of preventing the spread of MERS-CoV through the implementation of both B-IC and A-IC has not been published.

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The authors thank Elenette Prado, Department of Emergency Medicine, for providing secretarial assistance.

