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Transmission of Middle East Respiratory Syndrome Coronavirus Infections in Healthcare Settings, Abu Dhabi

Jennifer C Hunter et al. Emerg Infect Dis. 2016 Apr.

Abstract

Middle East respiratory syndrome coronavirus (MERS-CoV) infections sharply increased in the Arabian Peninsula during spring 2014. In Abu Dhabi, United Arab Emirates, these infections occurred primarily among healthcare workers and patients. To identify and describe epidemiologic and clinical characteristics of persons with healthcare-associated infection, we reviewed laboratory-confirmed MERS-CoV cases reported to the Health Authority of Abu Dhabi during January 1, 2013-May 9, 2014. Of 65 case-patients identified with MERS-CoV infection, 27 (42%) had healthcare-associated cases. Epidemiologic and genetic sequencing findings suggest that 3 healthcare clusters of MERS-CoV infection occurred, including 1 that resulted in 20 infected persons in 1 hospital. MERS-CoV in healthcare settings spread predominantly before MERS-CoV infection was diagnosed, underscoring the importance of increasing awareness and infection control measures at first points of entry to healthcare facilities.

Keywords: MERS-CoV; Middle East Respiratory Syndrome coronavirus; United Arab Emirates; coronavirus infections; healthcare-associated infections; nosocomial infections; transmission; viruses; zoonoses.

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Figures

Figure 1
Figure 1
Transmission of Middle East respiratory syndrome coronavirus (MERS-CoV) infections in 3 healthcare setting clusters, Abu Dhabi, January 2013–May 2014. A) Cluster I; B) cluster II; C) cluster III. Individual patients are identified by cluster and a letter indicating the order in which cases occurred (e.g., I-A indicates the source case-patient for cluster I). Figure panels illustrate suspected chains of transmission of MERS-CoV infection within the 3 clusters. Each circle represents a case-patient. Arrows connect case-patients with likely source of MERS-CoV infection, with arrows pointing in the direction of transmission (i.e., from source case-patient to secondary case-patient). Descriptions adjacent to arrows indicate the timing or location of confirmed (shown with solid arrows) and probable (shown with broken arrows) exposures between the case-patients. Asterisks (*) indicate case-patients who reported no fever or symptoms of respiratory disease; underlining indicates cases for which isolates underwent genetic sequencing. †Dates of exposure and symptom onset for case-patients III-B–III-L are summarized in Figure 2. ‡After identification of MERS-CoV in case-patient V, healthcare workers in unit A were screened beginning March 24, 2014. MERS-CoV was not detected from a sputum specimen collected from case-patient III-S at this time. The MERS-CoV–positive specimen was collected on April 24, after identification of case-patient III-Q on the same ward. HCA, healthcare-associated; HCW, healthcare worker.
Figure 2
Figure 2
Timeline of exposures, symptom onset, and diagnosis of Middle East respiratory syndrome coronavirus (MERS-CoV) among secondary case-patients in a healthcare-associated cluster (cluster III), Abu Dhabi, 2014. Colored boxes indicate key dates for each case-patient: green boxes indicate date of interaction between source case (patient III-A) and healthcare providers; pink boxes indicate date of symptom onset; blue boxes indicate date of MERS-CoV diagnosis. For 5 case-patients who reported no symptoms, symptom onset is not listed; data exclude a secondary case with probable exposure (patient III-Q). SOB, shortness of breath; ICU, intensive care unit; PPE, personal protective equipment; duration, duration of exposure; ED, emergency department.
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