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. 2018 Jan;28(1):51-63.
doi: 10.1111/ina.12430. Epub 2017 Oct 23.

A study of the probable transmission routes of MERS-CoV during the first hospital outbreak in the Republic of Korea

S Xiao  1 , Y Li  1 , M Sung  2 , J Wei  1 , Z Yang  3
Affiliations

A study of the probable transmission routes of MERS-CoV during the first hospital outbreak in the Republic of Korea

S Xiao et al. Indoor Air. 2018 Jan.

Abstract

Infections caused by the Middle East respiratory syndrome coronavirus (MERS-CoV) are a serious health issue due to their prevalence and associated mortality. However, the transmission routes of the virus remain unclear, and thus, the current recommended control strategies are not evidence based. In this study, we investigated the transmission routes of MERS-CoV during the first nosocomial outbreak in the Republic of Korea in May 2015 using a multi-agent modeling framework. We identified seven hypothesized transmission modes based on the three main transmission routes (long-range airborne, close contact, and fomite). The infection risks for each hypothesis were estimated using the multi-agent modeling framework. Least-squares fitting was conducted to compare the distribution of the predicted infection risk in the various scenarios with that of the reported attack rates and to identify the hypotheses with the best fit. In the scenarios in which the index patient was a super-spreader, our model simulations suggested that MERS-CoV probably spread via the long-range airborne route. However, it is possible that the index patient shed an average viral load comparable to the loads reported in the literature, and that transmission occurred via a combined long-range airborne and close contact route.

Keywords: Fomite; Middle East respiratory syndrome coronavirus; close contact; long-range airborne; multi-agent modeling; multi-route transmission.

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Figures

Figure 1
Figure 1
The three major transmission routes: close contact, fomite, and long‐range airborne routes. The person in red is the index patient
Figure 2
Figure 2
The layout of Pyeongtaek St. Mary's Hospital and a nearby building
Figure 3
Figure 3
Plan of the eighth floor of Pyeongtaek St. Mary's Hospital. The infected patients of the first generation and other inpatients are marked with solid circles of different colors. The source ward in which the index patient stayed is marked in light red. Adjacent, downstream, and remote wards are colored light blue, light brown, and light green, respectively. Room numbers are marked in black. The prevailing wind direction (westerly) is marked with a yellow arrow
Figure 4
Figure 4
System architecture of the multi‐agent modeling framework
Figure 5
Figure 5
Spatial distribution of the predicted average infection risk (for 1000 simulations) via three transmission routes at 24:00 on May 17, the end of the computational period. A, Long‐range airborne route. B, Close contact route. C, Fomite route. The largest virus‐containing droplet size d g = 100 μm, dose‐response parameters in respiratory tracts ηr = 3.2/mRNA copy and on mucous membranes ηm = 3.2 × 10−3/mRNA copy, and the viral load L 0 = 1010 mRNA copies/mL. Room numbers and the average infection risk in the room are marked in blue and red, respectively. Empty beds are marked in gray and occupied beds are red. Different levels of infection risk are represented by the intensity of red shading
Figure 6
Figure 6
Illustration of the hypotheses with the best fit (the minimum RSS) in the 1140 scenarios, with different values for the largest virus‐containing droplet size d g (20, 50, 100, and 200 μm) and products of viral load and dose‐response parameters in respiratory tracts ηr L 0 (21 values, 107 to 1012/ml) and on mucous membranes ηm L 0 (21 values, 104 to 109/ml). A, d g = 20 μm; B, d g = 50 μm; C, d g = 100 μm; D, d g = 200 μm. The different colored dots represent different hypotheses as shown in the legend. The dot size is inversely proportional to the value of the RSS. The eight more‐likely scenarios in Table 3 are shown with Roman numerals
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