Tuesday, July 24, 2018

BMC Inf. Dis.: Clinical Management Of Suspected MERS-CoV Cases


It has now been 71 days since the Saudi MOH last publicly reported on MERS-CoV cases via their surveillance website, and removed months worth of existing data.  The tightly controlled Saudi press has also been silent on MERS these past couple of months, and mention of  كورونا  - aka the  `Corona' virus - has been eerily absent from Arabic social media. 
We have seen some terse updates from WHO EMRO (see EMRO MERS-CoV Summary - June 2018) - and a more detailed WHO DON report current through the end of May - but at best, right now we are learning about cases anywhere from 2 to 6 weeks after the fact. 
This lack of reporting takes on increased importance as we are now less than 4 weeks from the start of the 2018 Hajj (est. August 19th), which will see millions of religious pilgrims arriving in the Kingdom from around the globe.

All able bodied Muslims are required to make at least one major pilgrimage to Mecca during their lifetime, at the time of the hajj. This is known as the fifth pillar of Islam, and is one of the duties incumbent upon all Muslims.
The faithful may also make `lesser pilgrimages’, called  omra (or Umrah), at other times of the year. These minor pilgrimages don’t absolve the faithful of making the hajj journey unless they take place during Ramadan.
As a result, the Kingdom of Saudi Arabia (KSA) receives more than 7 million visitors each year, with most of them arriving during the month of Ramadan (this year: May 15th-June 16th) and during the Hajj in August.
Coincidentally (or not), the Saudi MOH shut down MERS reporting on May 15th, the first day of Ramadan.
While we've been lucky in the past, with no large MERS outbreaks linked to the Hajj, the possibility of seeing one or more infected pilgrims returning to their home countries while silently incubating the virus is an annual concern.

Of course, the most likely infectious disease outbreak scenarios involve mosquito borne illnesses (like Dengue & Chikungunya, and now Zika), tuberculosis, mumps, measles, chickenpox, norovirus and respiratory viruses like seasonal influenza & Rhinovirus.
But it isn't lost on public health officials that the long incubation period (up to 14 days) and often subtle early symptoms (or asymptomatic carriage) of MERS makes early detection difficult.
Making this task even more challenging are the large number of non-MERS respiratory infections religious pilgrims tend to pick up on these trips.

In EID Journal: Respiratory Viruses & Bacteria Among Pilgrims During The 2013 Hajj, we saw a study that examined a small group of French pilgrims (n=129) both before and after attending the Hajj, and compared nasal swabs.  They found:
. . .  that performing the Hajj pilgrimage is associated with an increased occurrence of respiratory symptoms in most pilgrims; 8 of 10 pilgrims showed nasal or throat acquisition of respiratory pathogens.
Another study we looked at in 2012 – before MERS emerged - in  Clinical Infectious Diseases (co-authored by former Saudi Deputy Minister of Health, Ziad Memish) called - Unmasking Masks in Makkah: Preventing Influenza at Hajj  found:
Each year more than 2 million people from all over the world attend the Hajj pilgrimage to Saudi Arabia. At least 60% of them develop respiratory symptoms there or during outward or homebound transit [1, 2]
This heightened level of `viral noise’ among travelers returning from the Middle East makes it extremely challenging to identify and isolate those infected with MERS, Avian flu, or other highly virulent viruses (see MERS: The Limitations Of Airport Screening).
All of which brings us to a new research paper, published last week in BMC Infectious Diseases, that looks at the clinical management of suspected MERS cases in Paris, France between 2013 and 2016. 
While none of the 93 suspected cases tested positive for MERS-CoV, this report illustrates that returnees from Saudi Arabia exhibiting respiratory symptoms - particularly during the Hajj and/or Ramadan - require extra scrutiny by local health systems.

Clinical management of respiratory syndrome in patients hospitalized for suspected Middle East respiratory syndrome coronavirus infection in the Paris area from 2013 to 2016

A. BleibtreuEmail authorView ORCID ID profile, S. Jaureguiberry,
N. Houhou,  D. Boutolleau, H. Guillot, D. Vallois, J. C. Lucet, J. Robert, B. Mourvillier, J. Deemazure, M. Jaspard, F. X. Lescure, C. Rioux, E. Caumes† and Y. Yazdanapanah†
†Contributed equally
BMC Infectious Diseases201818:331


© The Author(s). 2018 Published: 16 July 2018



Patients with suspected Middle East respiratory syndrome coronavirus (MERS-CoV) infection should be hospitalized in isolation wards to avoid transmission. This suspicion can also lead to medical confusion and inappropriate management of acute respiratory syndrome due to causes other than MERS-CoV.


We studied the characteristics and outcome of patients hospitalized for suspected MERS-CoV infection in the isolation wards of two referral infectious disease departments in the Paris area between January 2013 and December 2016.


Of 93 adult patients (49 male (52.6%), median age 63.4 years) hospitalized, 82 out of 93 adult patients had returned from Saudi Arabia, and 74 of them were pilgrims (Hajj).
Chest X-ray findings were abnormal in 72 (77%) patients. The 93 patients were negative for MERS-CoV RT-PCR, and 70 (75.2%) patients had documented infection, 47 (50.5%) viral, 22 (23.6%) bacterial and one Plasmodium falciparum malaria. Microbiological analysis identified Rhinovirus (27.9%), Influenza virus (26.8%), Legionella pneumophila (7.5%), Streptococcus pneumoniae (7.5%), and non-MERS-coronavirus (6.4%). Antibiotics were initiated in 81 (87%) cases, with two antibiotics in 63 patients (67.7%).
The median duration of hospitalization and isolation was 3 days (1–33) and 24 h (8–92), respectively. Time of isolation decreased over time (P < 0.01). Two patients (2%) died.

The management of patients with possible MERS-CoV infection requires medical facilities with trained personnel, and rapid access to virological results. Empirical treatment with neuraminidase inhibitors and an association of antibiotics effective against S. pneumoniae and L. pneumophila are the cornerstones of the management of patients hospitalized for suspected MERS-CoV infection.

Thirty-six months ago we were watching the tragic results of a single MERS  infected business traveler returning from the Middle East to South Korea.

Although sparked by a single introduction, the virus spread like wildfire due to a handful of `super spreaders', whose impact was magnified by overcrowded hospital Emergency Rooms and hospital wards (see Superspreaders & The Korean MERS Epidemiological Report).

This unprecedented nosocomial outbreak spread across 16 hospitals in South Korea, where more than 185 patients, family members and staff were infected (see June 2015 WHO MERS Situation Assessment For Korea), with at least 37 deaths.
Thousands of exposed individuals - while not infected - found themselves quarantined at home and undergoing daily medical checks for the 14 day incubation period.
Beyond the loss of life, the political and economic costs were enormous.  And as we saw last month in Study: Burnout & PTSD Among Nurses Working During A Large MERS-CoV Outbreak - Korea, 2015, the emotional toll in the healthcare sector was substantial and persists.
While 99.999% of all returning Hajjis with respiratory symptoms will undoubtedly have something far less exotic or dangerous than MERS, the experience of South Korea shows that it only takes one case to slip through the cracks to spark a national crisis. 
For more on how this might be avoided, you may wish to revisit TFAH Issue Brief: Preparing The United States For MERS-CoV & Other Emerging Infections.

And of course, the same advice applies for other high impact  threats like avian influenza, Ebola, Nipah, Lassa Fever, Pneumonic Plague, and Disease X . . . the one we haven't seen before.

Because it only takes one. 

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