Making the Most of MERS

Published on June 12, 2014
When Saudi Arabia was hit by a deadly coronavirus, Qatari emergency physicians used it as an opportunity to catalyze hospitals into improving infectious disease practices.

In a bizarre twist of fate, I now find myself in the midst of a second deadly coronavirus outbreak. A decade after SARS – which I saw first hand while practicing in Hong Kong – I find myself working in Qatar and facing the Middle East Respiratory Syndrome (MERS), which originated in Saudi Arabia.

Being an emergency physician means that we are always on the frontline of any new epidemic or pandemic. In the last decade we have had “bird flu”, “swine flu”, SARS and now MERS, each of which put health care workers and patients in the ED at risk. In most cases involving infectious disease, the risk is most apparent after initial exposure has occurred. Which means that for emergency medicine, we have to assume the worst and protect our patients (and ourselves) on the basis of prioritization of risk without knowing what is actually going on.

The two coronavirus outbreaks (SARS and MERS) were particularly unusual in that they had the potential to explode into international pandemics and kill thousands (maybe even millions) but for some reason, stayed regional with only sporadic cases outside the epicentres of the outbreaks. Many groups have claimed credit for the containment of these epidemics, but no one can be certain exactly why there has been such limited spread. It is not even clear why the epidemics occurred when and where they did.

During the SARS epidemic in China and Hong Kong, there was a big increase in the number of cases over a couple of months in early 2003, then the virus seemed to “disappear” after a few months. Improvements in infection control procedures in hospitals and behavioural modifications within the community probably curtailed the epidemic, but this did not really explain the complete disappearance of the virus.

The MERS epidemic in the Middle East is now gaining some momentum, with most cases reported being in Saudi Arabia. There have been a few cases reported elsewhere but so far only from travelers coming from the Middle East. This is an unusual epidemic for a number of reasons. First, it has developed very slowly with only small numbers in any one centre. Second, it has a high mortality rate of 30-40% of cases reported. There appears to have been very few cases due to person-to-person spread, other than in hospitals (especially with healthcare workers). The origin of this outbreak is being slated to camels, where the virus has been isolated. However the epidemiology of many of the cases is difficult to trace back to camels!

As with the SARS outbreak, the politics of this infectious disease are possibly more serious than the actual disease. Hospital administrators and politicians who do not pay heed will lose their jobs and their reputations (as occurred recently in Saudi Arabia). The fact that many more patients will die from the daily influx of suboptimally-managed patients with septic shock, heart attacks and trauma, due to inadequate facilities, organisation and training does not register on the political radar. A handful of cases from an infectious disease outbreak will create community fear and loss of faith in public institutions. Health workers should not underestimate this effect on our political masters.

The impact of these few cases [of MERS] has been enormous, with a complete reorganization of patient flow within the main ED at Hamad General Hospital. All cases arriving to the ED with fever and cough are immediately isolated and given a mask. After a quick assessment, an X-Ray is performed and if positive for pneumonia, ongoing airborne isolation is enforced until two negative swabs for novel coronavirus are documented.

So far the MERS outbreak has caused more than 500 infections and more than 100 deaths globally. Fortunately, only nine cases have been reported in Qatar, even though it is immediately adjacent to the worst hit areas in Saudi. It is unlikely that there have been many more cases in Qatar because of the extremely active screening program that we have in place, especially for travelers returning from Saudi. The impact of these few cases has been enormous, with a complete reorganization of patient flow within the main ED at Hamad General Hospital. All cases arriving to the ED with fever and cough are immediately isolated and given a mask. After a quick assessment, an X-Ray is performed and if positive for pneumonia, ongoing airborne isolation is enforced until two negative swabs for novel coronavirus are documented. Patients without pneumonia and without other reasons for admission, are sent home for home isolation. Given that coughs and colds are common presentations to EDs and with a census of more than 1300 per day, the impact on patient flows is great. Fortunately the general public has remained calm and we have not had a large number of “worried well” attending the ED or primary health clinics. Although there has been a lot of media coverage, it has been responsible.

As a result of the outbreak, we have been able to enforce better isolation procedures for patients, improved infection control procedures (such as washing hands) and a major improvement in staff attitude toward vigilance in maintaining good infection control habits.

Thankfully, so far we have had no staff affected by the virus, and no new cases for the last 6 months. Importantly our infection control procedures for H1N1, measles, TB, meningitis and other infectious diseases have greatly improved. The hospital is also expanding the facilities for isolation rooms to cater to a much larger number than previously. Virology services have also improved with short turnaround times (<24 hours) for screening to rule out the disease. The outbreak has also allowed us to reinforce with the local community what strict isolation actually means. For example, when a 15-person family arrives to visit – and wants to spend the whole time with the patient -enforcement can be difficult, but it is improving!

Despite the evidence that good basic infection control will deliver most of the benefit, clinicians the world over seem to obsess over negative pressure rooms, hepafilters and advanced PPE. These are important for very high risk patients, such as those ventilated with proven infection undergoing respiratory procedures. They are simply not practical on an ongoing basis in busy overcrowded EDs for every potential case. Distraction with the high end infection control kit is a major concern when basic infection control guidelines are not being followed.

As emergency doctors we will be in the frontline when the next epidemic occurs. Having good patient flow through the ED, separating out patients with potential infectious disease syndromes and insisting on a high level of compliance with basic infection control procedures will prevent infections from most known infectious diseases. For the safety of the healthcare workers and the patients that you treat, it is imperative that a regular audit and feedback process are in place. Your ED shouldn’t need an epidemic to force your department to do what is expected. Nevertheless, an epidemic can be an opportunity, helping to catalyze the hospital into improving patient flow, reducing overcrowding in the ED and ramping up facilities for isolation and improved diagnostics.

WHO: Advice on MERS

from May 28, 2014

Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns.

Infection prevention and control measures are critical to prevent the possible spread of MERS-CoV in health care facilities. Health-care facilities that provide for patients suspected or confirmed to be infected with MERS-CoV infection should take appropriate measures to decrease the risk of transmission of the virus from an infected patient to other patients, health-care workers and visitors. Health-care workers should be educated, trained and refreshed with skills on infection prevention and control.

It is not always possible to identify patients with MERS-CoV early because some have mild or unusual symptoms. For this reason, it is important that health-care workers apply standard precautions consistently with all patients – regardless of their diagnosis – in all work practices all the time.

Droplet precautions should be added to the standard precautions when providing care to all 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.

Patients should be managed as potentially infected when the clinical and epidemiological clues strongly suggest MERS-CoV, even if an initial test on a nasopharyngeal swab is negative. Repeat testing should be done when the initial testing is negative, preferably on specimens from the lower respiratory tract.

Recent travellers returning from the Middle East who develop SARI should be tested for MERS-CoV as advised in the current surveillance recommendations. All Member States are reminded to promptly assess and notify WHO of any new case of infection with MERS-CoV, along with information about potential exposures that may have resulted in infection and a description of the clinical course. Investigation into the source of exposure should promptly be initiated to identify the mode of exposure, so that further transmission of the virus can be prevented.

People at high risk of severe disease due to MERS-CoV should avoid close contact with animals when visiting farms or barn areas where the virus is known to be potentially circulating.

WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.

This article originally appearing in Issue 13 of Emergency Physicians International.

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