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| MERS in KSA - A Fast Start For 2019 |
#14,029
Saudi Arabia is on track to exceed their 2018 total number of MERS cases (n=137) in the next few days or weeks, largely due to several hospital clusters which began in February and March (see WHO MERS Update - Saudi Arabia).
While we get very little real-time epidemiological data, delays in the diagnosis and isolation of suspected MERS cases likely contribute heavily to these nosocomial outbreaks.MERS - like most viral illnesses - can present with a wide spectrum of symptoms - ranging from mild to severe - and are often clinically indistinguishable from other, more common and routine respiratory infections.
We've looked at some of the substantial difficulties in diagnosing MERS coronavirus infection before, including atypical presentations, intermittent-positive test results, potential transmission from asymptomatic cases, and an unreliable algorithm used by the Saudis for screening patients. A few past blogs include:
AJIC:Intermittent Positive Testing For MERS-CoV
J. Korean Med Sci: Atypical Presentation Of A MERS Case In A Returning Traveler From Kuwait
JIDC: Atypical Presentation Of MERS-CoV In A Lebanese Patient
A Review Of Asymptomatic MERS Cases
Evaluation of a Visual Triage for the Screening of MERS-CoV PatientsDelays in diagnosis, as costly as they can be, are not always avoidable. Because of the difficulties in identifying cases, the WHO continues to advise:
It is not always possible to identify patients with MERS-CoV early because like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Therefore, healthcare workers should always apply standard precautions consistently with all patients, regardless of their diagnosis.
Droplet precautions should be added to the standard precautions when providing care to patients with symptoms of acute respiratory infection; contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection; airborne precautions should be applied when performing aerosol generating procedures.All of which brings us to a new open-access study, published in the Journal of Infection & Public Health, which attempts to quantify the delays in diagnosing MERS Cases - both before the infected individual seeks medical help - and after.
While the biggest factor between onset of symptoms and diagnosis were due to patient delays in seeking help, the medium health-system delay was 2 days.I've only include some excerpts from a much longer report, so follow the link to read it in its entirety.
Diagnostic delays in Middle East respiratory syndrome coronavirus patients and health systems
Anwar E.Ahmedabc
https://doi.org/10.1016/j.jiph.2019.04.002
Under a Creative Commons license
Abstract
Background
Although Middle East respiratory syndrome coronavirus (MERS-CoV) diagnostic delays remain a major challenge in health systems, the source of delays has not been recognized in the literature. The aim of this study is to quantify patient and health-system delays and to identify their associated factors.
Methods
The study of 266 patients was based on public source data from the World Health Organization (WHO) (January 2, 2017–May 16, 2018). The diagnostic delays, patient delays, and health-system delays were calculated and modelled using a Poisson regression analysis.
Results
In 266 MERS-CoV patients reported during the study period, the median diagnostic delays, patient delays, and health-system delays were 5 days (interquartile [IQR] range: 3–8 days), 4 days (IQR range: 2–7 days), and 2 days (IQR range: 1–2 days), respectively. Both patient delay (r = 0.894, P = 0.001) and health-system delay (r = 0.163, P = 0.025) were positively correlated with diagnostic delay.
Older age was associated with longer health-system delay (adjusted relative ratios (aRR), 1.011; 95% confidence intervals (CI), 1.004–1.017). Diagnostic delay (aRR, 1.137; 95% CI, 1.006–1.285) and health-system delays (aRR, 1.217; 95% CI, 1.003–1.476) were significantly longer in patients who died.
Conclusion
Delays in MERS-CoV diagnosis exist and may be attributable to patient delay and health-system delay as both were significantly correlated with longer diagnosis delay. Early MERS-CoV diagnosis may require more sensitive risk assessment tools to reduce avoidable delays, specifically those related to patients and health system.
(SNIP)
The study shows that median duration from the onset of MERS-CoV symptoms until first hospitalization (patient delay) was 4 days (IQR range: 2–7 days) with a range between 0 and 14 days. According to the study, patient delay significantly correlates with MERS-CoV diagnostic delay (r = 0.894, P = 0.001).The frequent long patient delay in seeking medical care after experiencing MERS-CoV symptoms may reflect limited patients’ awareness of, and knowledge of MERS-CoV symptoms [[9], [10], [11]] and the need for health education programs for the public [9,10], and healthcare practitioners [10,11]The median health-system delay was 2 days (IQR range: 1–2 days) with 86% of patients being diagnosed with MERS-CoV within two days after first hospitalization. This study shows that health-system delay significantly correlates with the MERS-CoV diagnostic delay (r = 0.163, P = 0.025).
The health-system delay in identifying a MERS-CoV case may be attributed to the delay in the virus recognition in medical institutions [6] and to the limited awareness among healthcare-workers [11], as a survey conducted on 1216 healthcare-workers revealed that only 47.6% of the physicians and 30.4% of the nurses were aware that some infected patients had no symptoms [11].Also diagnosis of MERS-CoV [3] and medical care for patients with MERS-CoV [12] remain major challenges in healthcare facilities. Further understanding on the causes of patient and health-system delay is needed, as it can be used as a modifiable factor to reduce diagnostic delay and to improve the diagnostic process.(Continue . . .)
While MERS-CoV hasn't embarked on a world tour the way that SARS-CoV did 16 years ago, we've seen studies (see A Pandemic Risk Assessment Of MERS-CoV In Saudi Arabia) suggesting the virus doesn't have all that far to evolve before it could pose a genuine global threat.
A year ago in the WHO List Of Blueprint Priority Diseases, we saw MERS-CoV listed among the 8 disease threats in need of urgent accelerated research and development.Among the tools needed are faster, and more accurate diagnostic tests, and an effective armamentarium of drugs and/or vaccines. Unless and until they become available, MERS is likely to continue to spark large healthcare-related outbreaks and remain a serious public health concern.
