In my last blog we looked at the press release from the World Health Organization (WPRO) (see The WHO Korean MERS Joint Mission Assessment ) which spoke in general terms about the findings of this high level panel.
Accompanying that release was a list of High Level Messages, outlining in more detail what was found and the panel's recommendations.
While not directly critical of the Korean response, using polite `diplo-speak' the panel pointed out the less than `optimal' infection control practices in many hospitals, the `unfamiliarity' of local physicians with MERS, and stressed the need for the government to improve their risk communications.
Although the onus is currently on Korea, many countries would do well to take a long hard look at the recommendations in this document, and take similar steps before they find themselves dealing with an imported case of MERS or avian flu of their own.
- This outbreak in the Republic of Korea, which started with the introduction of MERS-CoV infection into the country by a single infected traveller, was amplified by infection in hospitals and movement of cases within and among hospitals.
- A combination of older and new cases continues to be reported, but the epidemic curve shows that the number of new cases occurring each day appears to be declining. This decline has coincided with much stronger contact tracing, monitoring and quarantine, suggesting that disease control measures are working. These measures are greatly facilitated by expanded laboratory testing. However, several weeks will be required to confirm the impact of the measures and whether the outbreak is fully controlled.
- Several factors appear to have contributed to the initial spread of this virus.
- The appearance of MERS-CoV was unexpected and unfamiliar to most physicians
- Infection prevention and control measures in hospitals were not optimal
- Extremely crowded Emergency Rooms and multi-bed rooms contributed significantly to nosocomial infection in some hospitals.
- The practice of seeking care at a number of medical facilities(“doctor shopping”) may have been a contributing factor
- The custom of having many friends and family members accompanying or visiting patients may have contributed to secondary spread of infection among contacts.
- The rapid increase in numbers of cases has led to much speculation as to whether there may be new contributing factors to transmission. It is too early to draw definitive conclusions at this time, but certain observations can be made:
- There is no strong evidence at present to suggest that the virus has changed to make the virus more transmissible.
- Thus far, the epidemiological pattern of this outbreak appears similar to hospital-associated MERS-CoV outbreaks that have occurred in the Middle East. However, this Mission has not been able to determine whether environmental contamination, inadequate ventilation, or other factors have had a role in transmission of the virus in this outbreak. There is a compelling need for further investigation.
- While there is no evidence at present of ongoing community transmission of MERS-CoV in the Republic of Korea, continued monitoring for this possibility is critical. Because the outbreak has been large and complex and more cases can be anticipated, the Government should remain vigilant and continue intensified disease control, surveillance, and prevention measures until the outbreak is clearly over.
High Level Recommendations for Government
- Infection prevention and control measures should immediately be strengthened in all health care facilities across the country.
- All patients presenting with fever or respiratory symptoms should be asked about: contact with a MERS patient; visits to a healthcare facility where a MERS patient has been treated; and history of travel to the Middle East in the 14 days before symptom onset. Any patient with positive responses should be promptly reported to public health authorities and managed as a suspected case while the diagnosis is being confirmed.
- Close contacts of MERS cases should not travel during the period when they are being monitored for the development of symptoms.
- Strong consideration should be given to re-opening schools, as schools have not been linked to transmission of MERS-CoV in the Republic of Korea or elsewhere.
- The most important steps needed to stop further cases involve continued implementation of basic public health measures by all health authorities. These include:
- early and complete identification and investigation of all contacts
- robust quarantine/isolation and monitoring of all contacts and suspected cases
- full implementation of infection prevention and control measures; and
- prevention of travel, especially internationally, of infected persons and contacts
- Local governments must be fully engaged and mobilized in the national fight against this large and complex outbreak.
- In parallel with disease prevention and control measures, steps should be taken to strengthen domestic and international confidence and trust. The most important actions involve improving risk communications. The Ministry of Health and Welfare should provide regularly updated information (in Korean and English) on the epidemiological situation, investigations, and disease control measures.
- Additional staff (for “surge capacity”) are urgently required for the response and to provide relief for staff already working on the outbreak.
- Selected hospitals should be designated for safe triage and assessment of suspected MERS cases. This will require trained personnel, facility management, and communication with the public.
- Comprehensive research studies designed to close critical gaps in knowledge, including sero-epidemiological studies, should be completed and the results widely communicated as quickly as possible.
- The Republic of Korea should ensure that it is able to optimally respond to future outbreaks. In particular, it should strengthen the medical facilities needed to deal with serious infectious diseases, including increased numbers of negative-pressure isolation rooms; consider how to reduce the practice of “doctor shopping”; train more infection prevention and control specialists, infectious disease experts, laboratory scientists, epidemiologists, and risk communication experts; and invest in strengthening public health capacities and leadership, including at Korea Centers for Disease Control and Prevention (KCDC).