Comprehensive understanding of nosocomial #MERS outbreaks

Since 2014, we assist a continuous spread of MERS outbreak, moslty occuring in medical facilities.

After South Korea (SK), turn back to KSA and Riyadh main hospital facility where an ongoing nosocomial outbreak is occuring . It is not a matter of means or competency , it seems to be more related to a management system of the emergencies.Jeddah emergency ward

Recent lessons learned from SK demonstrate that MERS spread risk factors are related to overcrowded rooms, lack of air-conditioning and/or contaminated air filters, very long wait.

Today, it might be interesting for a better understanding of the root causes, to follow the “patient path” and address time and space issues from arrival/admittance at the hospital till hospitalization or release.

overcrowded ER

Who is the first health care worker (HCW) and position allowed and able to take care of a suspicious infected person?

How is this HCW protected? Are standard precautions (gloves, facial masks,coverall,glasses) implemented and applied? As a minimum, any new case arriving at ER would have to wear a facial mask and hand sanitizing…

The second point to raise is the best practice for sorting People who are admitted at the ER and based on which criteria:

  • suspicious case of infection with fever?
  • complication or illness related to an underlying medical condition (diabetes,renal failure,respiratory failure,…)?
  • or both?

Behind this first “gate control”, then a split between infected/non infected based on symptomatic/asymptomatic cases would lead to decision for isolating/quarantine and waiting for further investigation and testing.  Any positive test for MERS-CoV would trigger a track of contacts.

We know that MERS-CoV is not an easy spreading virus from human to human, but, under certain circumstances like close contacts in confined space could be responsible for contamination either to relatives, other hospitalized People or even worse, HCW if unprotected.

Regarding architecture of buildings where emergency wards are installed, it is important to address the impact assessment of contamination risk depending of both vertical and horizontal positions. With regards to this specific issue, it is amazing to look back in the past, when residential hospital model, in early XX° century, was built to prevent infectious diseases from spreading indoor and outdoor. Nowadays, we are focusing more  on air conditioned tower and its risk of Legionella or on air filters like for MERS Coronavirus in SK.

The new architecture of hospitals is more (internal and external) customer orientated, developing easy access through corridors or lifts, gangways and subways in order to facilitate communication and transfer of patients but also and by the way, facilitating the spread of virus and bacteria…except in restricted areas like operating room, ICU where specific procedures are in force.

nosocomial risk assessment

Unfortunately, HCW are not champion for hand hygiene and sanitation, especially during care management by passing from one patient to another without applying mandatory process for decontamination.

Now, we have all we need to have to understand the occurence of a nosocomial MERS outbreak. An Hazard analysis critical control point would prevent from a cross-contamination by regulating the flow of patients arriving and staying in ER.

Another lesson learned from avian Flu H1N1 pandemics is to inform suspected infected patients and for asymptomatic ones to prevent from coming to ER; putting in place a phone call number like 911 in case of an emergency and to organize a safe and secured ground transportation by ambulance driven by protected and trained paramedics.

Patients and their relatives or visitors would be aware about the health risks related from getting MERS; they could become vector of the coronavirus. So, hygiene measures including hand sanitation and cough etiquette are of great importance and must be highlighted by Health authorities.

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