The Saudi MOH has done a much better job in recent months of conveying information about their MERS response via a Weekly MERS Monitor report from their CCC (Command & Control Centre), which are published at this link.
This week, the focus is on the causes of Health Care Facility (HCF) related outbreaks.
While sporadic and widely scattered `primary cases' continue to turn up around the country (some, but not all related to camel exposure), health care facilities have frequently served as outbreak amplifiers. Over the past year we've seen:
- Last month's outbreak in Buraidah involved 8 primary cases, and 20 secondary cases, most of which occurred in their local hospital.
- During 2015's summer outbreak in Riyadh (see Saudi MOH Statement On The Riyadh MERS Outbreak – Aug 23rd), the MOH cited 53 cases & 17 deaths at Riyadh’s National Guard Hospital.
- Last year's hospital outbreak in Hofuf involved over 40 cases.
Today the Saudi MOH takes a look at some of the root causes behind these large hospital outbreaks, and outline some badly needed policy changes.
The Command and Control Centre reviewed common factors associated with the emergence of MERS outbreaks in HCFs.
Number of common factors have been observed during investigations of MERS outbreaks in HCFs in Saudi Arabia (Figure 1). These factors were linked to the surge of the health acquired secondary cases of MERS, including Health Care Workers (HCWs). Identifying and addressing these gaps provide an opportunity to prevent future outbreaks.
This is the kind of public introspection and analysis we're not used to seeing from the Saudi MOH, but assuming it continues, it constitutes a very welcome change.
Many of MERS outbreaks originated in the Emergency Department (ED). Almost all MERS outbreaks in HCFs stemmed from one or more of the following factors:
- Inadequate awareness of physicians to the case definition of MERS;
- insufficient adherence to Infection Prevention and Control (IPC) practices and procedures especially during Aerosol Generating Pro-cedures (AGP), by not wearing proper Personal Protective Equipment (PPE), or performing AGP in rooms with no negative pressure; inadequate imple-mentation of respiratory triaging of cases;
- discharge against medical advice and inadequate communication of such incidents;
- gaps and flaws in the referral mechanism of MERS cases;
- overcrowded ED and irregular control of entrances;
- and inadequate control of visitation.
Temporary solutions like intensified IPC measures during the incident of an outbreak is valuable but would not address the root cause of the intra-hospital and/or hospital-to-hospital transmission of MERS. Therefore, number of decisions and recommendations have been negotiated to resolve the frequent factors that led to MERS outbreaks in the HCFs.
Capacity enhancement through mandatory training on infection control practices is necessary to keep HCWs aware and alert, especially staff in the EDs. Moreover, triage training and increasing awareness of case definitions for MERS will improve the efficiency of capturing susceptible cases in the EDs. Rearranging triage area and controlling access to EDs should all be considered to protect both of patients and HCWs.
Simple yet very important modifications would have greater impact in minimizing MERS outbreaks in the HCFs. Ministry of Health is working on bridging these gaps through improving communication and continuous follow-up.