Thursday, April 14, 2016

EID Journal: Large Hospital Outbreak Of MERS-CoV - Jeddah, Saudi Arabia, 2014


During the spring of 2014 Saudi Arabia saw its largest outbreak of MERS cases on record, with more than 400 cases reported from multiple locations between April and June (plus 113 `retrospectively' identified cases).  

While daily reports from the Saudi MOH were lacking in detail, it was apparent that Hospitals in and around Jeddah were particularly hard hit (see Saudi MOH Statement On Jeddah Cluster).

Limited details on those spring cases were `compressed' into a single WHO statement issued in mid-June (see WHO MERS Update For UAE, Saudi Arabia & Iran), where we learned:

Details of the cases reported by Saudi Arabia are as follows:
Between 11 April and 9 June 2014, 515 cases of infection with Middle East respiratory syndrome coronavirus (MERS-CoV) have been reported from Saudi Arabia to WHO. This includes 402 laboratory-confirmed cases reported on various dates, and 113 cases that have been identified through retrospective review of hospital records, and which was reported by Saudi Arabia on 3 June. Further information on these cases will be provided as information becomes available as part of the collaboration between the Saudi authorities and WHO on the MERS-CoV response.

This update covers 402 laboratory-confirmed cases, including 114 deaths.
Thirty-five cases were reported from Madina, 132 from Riyadh, 208 from Mecca Province (including 154 from Jeddah, 39 from Mecca, 8 from Qunfudhah and 7 from Al Taif), 10 from Tabuk, 6 from Al Jawf, 3 from Najran, and 3 from Ash Sharqiyah. The location from where 5 cases were reported was not specified. 
(Continue . . .)

In what seems related to a new level of openness on the part of the Saudi MOH, over the past few months details on several high profile nosocomial outbreaks have been published, including EID Journal: Multi-facility Outbreak of MERS in Taif, Saudi Arabia  and  MMWR: A Large Nosocomial Outbreak Of MERS In Riyadh - Summer 2015). 

Last night the CDC's EID Journal published our first detailed look at the large nosocomial outbreak at King Fahd Hospital in Jeddah, during the spring of 2014.  

While early speculation focused heavily on the hospital's renal dialysis unit, this report finds that multiple locations in the hospital likely helped to amplify the outbreak. 

Volume 22, Number 5—May 2016


Outbreak of Middle East Respiratory Syndrome at Tertiary Care Hospital, Jeddah, Saudi Arabia, 2014

Deborah L. Hastings1, Jerome I. Tokars1, Inas Zakaria A.M. Abdel Aziz, Khulud Z. Alkhaldi, Areej T. Bensadek, Basem M. Alraddadi, Hani Jokhdar, John A. Jernigan, Mohammed A. Garout2, Sara M. Tomczyk, Ikwo K. Oboho, Andrew I. Geller, Nimalan Arinaminpathy, David L. Swerdlow3, and Tariq A. MadaniComments to Author


During March–May 2014, a Middle East respiratory syndrome (MERS) outbreak occurred in Jeddah, Saudi Arabia, that included many persons who worked or received medical treatment at King Fahd General Hospital. We investigated 78 persons who had laboratory-confirmed MERS during March 2–May 10 and documented contact at this hospital. 

The 78 persons with MERS comprised 53 patients, 16 healthcare workers, and 9 visitors. Among the 53 patients, the most probable sites of acquisition were the emergency department (22 patients), inpatient areas (17), dialysis unit (11), and outpatient areas (3). 

Infection control deficiencies included limited separation of suspected MERS patients, patient crowding, and inconsistent use of infection control precautions; aggressive improvements in these deficiencies preceded a decline in cases. MERS coronavirus transmission probably was multifocal, occurring in multiple hospital settings. Continued vigilance and strict application of infection control precautions are necessary to prevent future MERS outbreaks.


In conclusion, the MERS outbreak at KFGH affected patients and HCWs. Illness most likely was transmitted in multiple settings, making it difficult to track disease from patient-to-patient. The contribution to MERS-CoV transmission at KFGH by asymptomatic persons is uncertain; transmission by asymptomatic persons is an area that needs further study. Heightened awareness of MERS, aggressive triaging of patients, prompt isolation, and strict infection control measures were associated with a rapid decrease in transmission. Continued vigilance and consistent adherence to infection control precautions is necessary to prevent future healthcare-acquired MERS outbreaks.
At the time of the investigation, Dr. Hastings was an Epidemic Intelligence Service officer at the Centers for Disease Control and Prevention, assigned as a field officer; she currently works in the Division for Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC. Her research interests include injury prevention and environmentally caused illnesses.

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