key: cord-009476-4emc4o6n
authors: Madani, Tariq A
title: Case definition and management of patients with MERS coronavirus in Saudi Arabia
date: 2014-09-22
journal: Lancet Infect Dis
DOI: 10.1016/s1473-3099(14)70918-1
sha: 
doc_id: 9476
cord_uid: 4emc4o6n

nan

The threat to global health security from emerging and re-merging respiratory tract infections will be ever present because of the genetic adaptability of microbes, and their ability to resist clinical interventions and public health measures aimed at their elimination. Although much has been learned from previous outbreaks, present surveillance systems have their inherent weaknesses, and recent experiences with MERS-CoV 14 show that pandemic preparedness still faces major political and scientifi c challenges. 15 An important priority for control of infectious disease is to ensure that scientifi c and technological advances in molecular diagnostics and bioinformatics are well integrated into public health. More eff ective and wider partnerships based on equity and best ethical practice, across governments, health care, academia, industry, and with the public, are essential to eff ectively galvanise economic, political and scientifi c measures required to develop core capacities, including legislation, national focal points, and pandemic planning to reduce risk of global spread and reduce the burden of respiratory tract infectious diseases. An urgent need exists to establish trusting and eff ective meaningful collaborations between countries to tackle new emerging microbial threats. This will facilitate early and rapid detection of potential pandemic infectious diseases through public health actions within the framework of the International Health Regulations. 16 outbreak and prevent human-to-human and animalto-human transmission; an appropriate management algorithm, including best-practice guidelines for accurate diagnosis, infection control, intensive care, emergency medicine, and treatment; prioritise research related to the MERS-CoV outbreak such as case-control and cohort studies, seroprevalence studies, and clinical trials; and to eff ectively monitor outbreak control activities.

A continously operating command and control centre was established in the minister's office. In addition to the advisory council, nine further platforms were established: interministerial to coordinate efforts between the Ministry of Health (MOH) and other concerned ministries; capacitybuilding to recruit and mobilise qualified staff to work in hospitals treating patients with MERS-CoV, increase the number of beds in intensive care units, and provide state-of-the-art machines such as extracorporeal membrane oxygenation to treat patients with respiratory failure refractory to conventional ventilation; public relations to communicate relevant information to the public, health-care workers, and local and international media; clinical operation to coordinate management of patients and transfers between hospitals; public health to collect data related to patients and their contacts; data analysis to enter and analyse data; epidemiological to provide consultations on data analysis and interpretation; laboratory to ensure fast and reliable diagnostic testing; and, infection control to oversee infection control practice and staff training activities.

A MERS referral hospital run by well trained staff was designated in Riyadh, Jeddah, and Dammam to receive and manage all patients infected with MERS-CoV. The MOH enforced strict infection prevention As new clinical information became available, a revision of the MERS-CoV case defi nition seemed appropriate. 2 The new case defi nition (appendix) was developed based on reported health-care-associated MERS-CoV pneumonia (added as category 2 in the new case defi nition) and non-respiratory characteristics of patients with confi rmed infection who fi rst presented with acute febrile dengue-like illness with body aches, leucopenia, and thrombocytopenia (added as category 3). The new case defi nition added a fourth category for contacts of people with MERS-CoV who present with not only lower respiratory tract but also isolated upper respiratory tract features. This defi nition classifi ed the status of patients into three categories of suspect, probable, or confi rmed infection. The new MERS-CoV case defi nition was revised and approved by the advisory council after seeking external CDC expert opinion.

An algorithm for MERS-CoV case management was developed (fi gure). According to this algorithm, patients with confi rmed MERS-CoV who have no evidence of pneumonia or who recover from pneu monia but remain positive for MERS-CoV, can be isolated at home after careful assessment of the home situation and suitability for isolation by the treating physician, highly trained social workers, or other health-care professionals by telephone or home visits. The CDC has released recommendations on how to assess the home situation and the advice to be given to patients on home isolation and his or her caregivers and household members, 3 and also released guidance for the public, clinicians, and public-health authorities in the USA on control of the MERS-CoV infection. 4

Ministry of Health, Riyadh, Saudi Arabia; and Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia tmadani@kau.edu.sa

Tim Uyeki, and Ray Arthur for their critical review of the case defi nition and the MERS-CoV case management algorithm, and Fadwa Mushtaq for her secretarial assistance

World Health Organization. WHO experts probe Middle-Eastern respiratory syndrome coronavirus (MERS-CoV

World Health Organization. WHO Revised interim case defi nition for reporting to WHO-Middle East respiratory syndrome coronavirus (MERS-CoV): as of

US Centers for Disease Control and prevention. Interim infection prevention and control recommendations for hospitalized patients with Middle East respiratory syndrome coronavirus

First confi rmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in the United States, updated information on the epidemiology of MERS-CoV infection, and guidance for the public, clinicians, and Public Health Authorities

Health-care-associated bacterial infections are an important cause of morbidity and mortality in critically ill patients, especially patients needing mechanical ventilation. Decolonisation with topical antibiotics, such as selective digestive tract decontamination (SDD) or selective oropharyngeal decontamination (SOD), eradicates potentially pathogenic bacteria, preventing ventilator-associated pneumonia and bacteraemia. In two Dutch studies, 1,2 SDD and SOD reduced mortality, intensive-care unit (ICU) length of stay, ICU-acquired bacteraemia, and carriage with antibiotic-resistant bacteria. Accordingly, both measures were deemed cost eff ective. 3 Only studies that assessed the unit-wide implementation of SDD or SOD provide evidence of a