Hajj 2015, Health and Safety: #MERS is not the main concern!

To think the unthinkable in order to organize a preparedness plan to cope with mass gathering situations: That is part of the job of a risk assessment. Regarding health issues and risks related to MERS, please refer to weak signals of an outbreak during the Hajj.

But this year we are also assisting to major accidents with huge number of casualties and Mass gathering Hajj_2015fatalities; first related to the crane crash in the Grand Mosque (Mecca) and now hundreds of pilgrims dead in stampede.

ambulances

Despite reassuring News from WHO EMRO, there is a clear evidence that safety and security are not in place to prevent this kind of chaos.

Consequence management might be of great importance with regards Public Health issues when facing multiple casualties which could lead to overwhelming the local medical facilities and ER capabilities.

On a Health and Safety risk management, it is a bit disappointing to address high risks leading to recovery measures where and when pro-active measures could have avoided so many dead Pilgrims. Lack of safety and security measures to be pointed out.

Same remarks for MERS when we see camel pens reappearing in Jeddah or camel meat prepared for the pilgrims despite Saudi Authorities recommendations.

How could the overcrowded ER all around the holy cities hint by these accidents could control and prevent the emergence of a MERS outbreak, just in case???

#MERS,Hajj and weak signals of an outbreak

When reviewing some of the last outbreak,especially Ebola in West Africa, we can identify clues, facts which might have been classified as weak signals of the spread of an outbreak. The chronicle of a death foretold….

signaux faibles_weak signals

Medical scientists community is raising alarm about MERS coronavirus since 2013, by following clusters then outbreak of MERS cases. Recently, it has been demonstrated that nosocomial outbreak model can be exported and may be consider as a public health Emergency of international concern ( PHEIC).

Today, as the Hajj will start around September 21st, we have to address a risk Hajj_locations_and_ritesassessment of Mers for’the huge amount of Pilgrims traveling to and from Mecca, Jeddah and Madinah, holy locations.

As explained before, nosocomial outbreak is a sum of several hazards occurring at the same time and at the same location due to a multifactorial combination.

for more details, refer to Hajj surrounded by sporadic Mers cases and nosocomial infection in Riyadh

image

Hajj 2015 is gathering several warnings:

  • Mers coronavirus is circulating (Jeddah,Madinah)
  • several clusters
  • big nosocomial outbreak in KAMC-R
  • Gaps and failure of ICP in hospitals
  • weather forecast: extreme heat, sandstorm, storms
  • Huge mass gathering
  • big accident in Mecca with more than hundred deaths at least and numerous casualties due to crane crash in the holy sanctuary => Mass casualties gathering in ER.
  • Camels slaughter in some places
  • Pilgrims behavior and camel food habits (raw milk, meat…)

image

You may have a look at: Toppling Cranes Aren’t the Only Things Threatening Mecca

and People with chronic diseases advised to postpone Haj as the most exposed People (high risk of MERS) are both elderly and sick ones.

How difficult it is to maintain a healthy and safe environment all around the holy cities: Random camel pens surface anew in JeddahHaj 2015: Pilgrims eat 100 camels a day

Camel pens

Now if we caculate the probability for the emergence of a spread of MERS leading to an outbreak by adding these risk factors, we are between 50% and 1.

Risk factors of #MERS Coronavirus nosocomial infection

Recently a good question was raised by @gwendolbowling about the occurrence of a nosocomial infection in an university hospital, referenced as best of the class?

BVF

My first answer was to refer to a continous quality improvement process/PDCA wheel by including on a regular basis, health process audit and ICP inspection; as explained in another blog (Comprehensive understanding of nosocomial #MERS outbreaks), to track and check any critical point which might be responsible for a cross contamination leading to nosocomial infection.

Humor

There are different types of risk factors which contribute to trigger off a nosocomial infection:

  • Architecture:residential hospital preferable for admitting/treating infectious diseases
  • Logistics and hospitalization:a step by step inspection from supply (income), management of care (indoor) to waste management (outcome).

Noso Tab

It is always a multifactorial root causes tree which explains the occurrence of nosocomial infection.

screen prevention

Replace Malaria by MERS in the figure and you understand that several screens exist to prevent infection and each time one screen is missing then there is an increase of the infection risk leading to possible nosocomial infection. In other words, a lack of ICP is responsible for nosocomial outbreak.

By conducting an health process audit focusing on ICP, close to HACCP audit for water and food safety, it is possible to identify gaps, critical points and cross contamination risks due to lack of controls or absence of preventive measures (primary,secondary or tertiary).

What do we observe for MERS as a nosocomial infection leading to outbreak? It starts with one index case, infected outside the hospital (at home or workplace) who is admitted at the emergency room. He is waiting for a long time, sharing the overcrowded location with other ill people. As he is not identified as MERS carrier, HCW do not apply on a 24/7 the ICP by wearing adequate PPE; HCW become ill but also vector for spreading MERS infection to others, mostly by close contact (MERS is not an airborne disease), leading to an intra hospital outbreak: this is the chain reaction described in Nosocomial Mers outbreak in Riyadh.

Accident-Trajectory-Reasons-Swiss-Cheese-Model

But we have to consider that there are alternative ways to contaminate an hospital building and it is of great importance to audit the logistics process: what is going in (food, medical equipment/tools, linen) and waste management coming from infected patient, classified as bio-hazard with a specific way for elimination. Here we are talking also about hygiene and sterilization inside the hospital.

cleaning

Cleaning, hand sanitazing, by insisting on specs related to MERS-CoV which can contaminate from fomites, some of them staying on sponges or rags for a while.

Implementing ICP is one thing; auditing and checking on regular basis that procedures are applyed and that performances show a low rate of nosocomial infection are the key values to prevent outbreak. Training, drills and performance review are part of the ICP.

At this stage, it is easier to understand why a nosocomial outbreak can occur even in the most famous international university hospital if there is one or multiple failures in the ICP. Zero nosocomial infection remains a day to day challenge.

Reference: Prevention of hospital-acquired infections A PRACTICAL GUIDE by WHO,2002

#MERS Coronavirus in KSA and The Conspiracy Theory

Local viewpoint:MOH has failed to control Mers.It is always alarming whenever we are facing a conspiracy theory and especially when this theory is supported by the Authorized Persons locally. Most of the time, that points out a weakness with regards the way to managing the threat of an ongoing MERS outbreak.image

Considering that things are not under and before they become out of control despite action plan (ICP) to stop a huge nosocomial infection occurring in the main national hospitals, it is easier and more convenient to elaborate a conspiracy theory. To keep in mind that 33% of Mers cases are nosocomial infection.

But such a theory does not resist to scientific peer review: MERS is existing since 2012 and coronavirus is hosted by dromedary camels since decades, starting in North then Horn of Africa before reaching Middle-East. Last year Dr Ian Mackay wrote that MERS came from camels, not terrorists

On one hand, scientists (Virologists, Epidemiologists, Veterinarians) are gathering evidence based on facts; on the other hand, there are tweets sent by honourable Faculty members denying the evidence based medecine regarding MERS-CoV.

Last, not least, The Under secretary of MOH is pleading for a “plausible” bio-weapon of MERS-Coronavirus. see ‘Plausible’ that MERS was developed as bio-weapon

Miscommunication on Mers issues and impacts?

I don’t like speculating on this matter but I would not be surprised to watch an increase of MERS cases among Hajj Pilgrims by the end of September, early October outside of KSA on their way back to home countries.

Poor risk assessment of what a bio-weapon would meet as a minimum requirement to be classified as a threat; clear demonstration of lack of knowledge about MERS which reminds me the same story heard in West Africa during the Ebola outbreak…

Imaging a bio-weapon dedicated to disable and targeting Population with chronic diseases and underlying poor medical conditions? Come on…

Towards a #MERS Vaccine? Who is the target?

Helen Branswell has recently published Camel vaccine against MERS could slow human to camel infections.

In its 10th meeting hold on september 3rd, IHR Emergency Committee of WHO addressed a couple of things related to vaccine:

WHO Statement on 10th meeting IHR/EC

  • International collaboration to develop human and animal vaccines and therapeutics should be accelerated.

Laboratories have launched their battle-field researchers in order to be the first to produce a vaccine against MERS; whatever the vaccine would be?

Mers-virus-3D-image

Since 2012, Virology and Epidemiology have brought on the table a lot of information about the virus itself, a coronavirus, same family of SARS virus.

As of today we know how MERS is operating as an infectious disease, hosted by dromadary camels mainly in Middle-East (>90% infected), starting by a zoonosis then spreading human to human through clusters in household or nosocomial infection in the hospitals.

Two kinds of infected (by Mers-Cov) population have emerged in KSA:

  • symptomatic:either elderly or People with underlying poor medical conditions or chronic diseases including but not limited to diabetes,chronic renal failure, cardio-respiratory diseases or immunosuppressed
  • asymptomatic:healthy carriers

Root causes,mitigations and prevention of MERS-CoV_2015

Identifying healthy carriers, asymptomatic ones is based on positive testing, sometimes in link with health risks exposure like camels herds owners, slaughterhouse workers, or health care workers (HCW). Even if prevalence is quite low, we have identified a life cycle for Mers infection and outbreaks (see chart).

It is not the purpose here to review the conditions for nosocomial outbreak at the hospitals; see: Follow-up of the nosocomial #MERS outbreak in Riyadh,KSA

Knowing that, how could we prevent MERS from spreading both at community hospital level and at household level? Would it be realistic to vaccine the entire KSA population or only People at high risks? Would such a vaccination program prevent actually MERS from spreading?

Or do we focus on the source of MERS Coronavirus, I mean dromadary camels and manly young calves under 5 years old? It would make more sense with a long lasting and sustainable outcome to prevent Mers coronavirus from jumping outside of animal to human; in other words to prevent a zoonosis?

The answer seems obviously understood in the question…KSA MOH is supporting and sponsoring the idea of an animal vaccine by working hard on this issue.

Riyadh’s #MERS outbreak diary and Hajj

Update on November 12th 2015

Today, one secondary case in Riyadh, after 8 days free of MERS, due to contact with infected HCW. The previous one was a primary case on November 3rd.

On November 2nd, one primary case reported in Afif.

A new cluster occured in Hufoof. In fact a nosocomial MERS Outbreak!

  • 8 cases as of today (Oct.29th), including HCW. Not the first time in that location where ocurred a nosocomial outbreak some time ago…

On October 17th, one case in Dawadmi, west of Riyadh. One month ago, 1 case (without previous contact) on September 9th in Dawadmi;

On October 24th, an expat, male, positive for MERS; primary case in Alkharj.

  1. Hajj: hundred of deaths during stampede in Mina: More than 1800 Pilgrims died. This raised the question about Health and safety during the Hajj. The worse record related to Hajj…
  2. Third birthday of MERS; take the time to read the review by Dr Mackay’s Blog called VDU (Virology Down Under):Happy Birthday MERS-Coronavirus!
  3. One month ago, we learned there was an ongoing nosocomial Mers outbreak at KAMC hospital.
    • Total Mers cases in August = 112 cases in Riyadh.
    • Total Mers cases in September = 43. 
    • Total Mers cases in October = 12

Is the nosocomial outbreak in KAMC-R under containment? Seems to be over now.

October starts with one new case in Nora University, Riyadh. After one week free of Mers,on october 10th another case has been recorded. On Oct.11th, a new one. On Oct.13th another one.

The last 3 ones are young expat ladies, non HCW =>A new cluster? I guess so by adding the third case reported today, another young expat lady. No more doubt to declare there is an outbreak in Expat community of the young Ladies.

On October 15th, MOH has posted a brief statement acknowledging the cluster, emphasizing these are ex-pat workers housed away from the university, and confirming additional members of the housing complex are under house quarantine.

KAMC hospital

In the last release by WHO on August 26th, it is stipulated that a second smaller medical facility in Riyadh reports another nosocomial outbreak. So far, two main hospitals are closed in Riyadh due to Mers outbreak. It is surprising to record new HCW cases; the onset around 14 days mean that HCW have been infected/contaminated while nosocomial outbreak occurring despite precautionary and mitigation measures. Still concerning…for containment and ICP in Riyadh.

Hajj Mecca

Remember this? On thursday Aug 27th, There was a suspicion for a new cluster in Jeddah and rumors that the National Guard Hospital has closed following 5 Mers cases (not confirmed).

On Saturday 9/12, one positive case of Mers for a HCW in Jeddah; on September 18th, 1 Mers case recorded.  Today, another case. At least 3 recent cases close to holy city Mecca. Low but continuous pace in this area; might be sporadic cases but no link reported…background sound spread?

One suspected case moved in August from Madinah to Riyadh as a precautionary measure…we know why now! On September 7th, one new case + another one (HCW) on Sept.10th. On 9/11, 3 new cases (with 2 HCW who were transferred to KAMC-R ) reported in Madinah. On Sunday 9/13, one more case (HCW) and today (9/14) another one

  • Total= 8 cases . Very concerning with 4 HCW infected…(50%).

 

Outside of KSA,

  • Jordan: Since mi-August, 16 cases in the same hospital in Amman, including 7 deaths .First case described as coming from KSA (Jeddah). No more doubt; There is one MERS nosocomial outbreak in Amman, confirmed by WHO. No Hajj Piligrims infected so far…
  • Kuwait: One fatality case who was tested positive on September 14th and’ reported on 20th.
  • No recent news and update about these two countries…

Interesting review by Ian Mackay on the occurence of MERS in KSA:

Where do these ‘primary’ MERS cases come from?

MERS Statistics by @MackayIM

To learn more, refer to: Towards a #MERS vaccine? Who is the target?

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 occurring . 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.