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Nath M, Debnath P. Therapeutic role of traditionally used Indian medicinal plants and spices in combating COVID-19 pandemic situation. J Biomol Struct Dyn 2022:1-20. [PMID: 35773779 DOI: 10.1080/07391102.2022.2093793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The coronavirus disease (COVID-19) caused by SARS-CoV-2 is a big challenge and burning issue to the scientific community and doctors worldwide. Globally, COVID-19 has created a health disaster and adversely affects the economic growth. Although some vaccines have already emerged, no therapeutic medication has yet been approved by FDA for the treatment of COVID-19 patients. Traditionally, we have been using different medicinal plants like neem, tulsi, tea, and many spices like garlic, ginger, turmeric, black seed, onion, etc. for the treatment of flu-like diseases. In this paper, we are highlighting the recent research progress in the identification of natural products from the Indian medicinal plants and spices that have potential inhibition properties against SARS-CoV-2. This study will provide an initiative to stimulate further research by providing useful guidance to the medicinal chemists for designing new protease inhibitors effective against SARS-CoV-2 in future.
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Affiliation(s)
- Moumita Nath
- Department of Botany, Tripura University, Suryamaninagar, Tripura, India
| | - Pradip Debnath
- Department of Chemistry, Maharaja Bir Bikram College, Agartala, Tripura, India
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Okumus B. Norovirus and Coronavirus Risks in Food Service Settings: A Systematic Review for Future Research. JOURNAL OF CULINARY SCIENCE & TECHNOLOGY 2021. [DOI: 10.1080/15428052.2021.1888835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Bendegul Okumus
- Food Service and Lodging Management Department, Rosen College of Hospitality Management, University of Central Florida, Orlando, FL USA
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Shahrajabian MH, Sun W, Cheng Q. Product of natural evolution (SARS, MERS, and SARS-CoV-2); deadly diseases, from SARS to SARS-CoV-2. Hum Vaccin Immunother 2021; 17:62-83. [PMID: 32783700 PMCID: PMC7872062 DOI: 10.1080/21645515.2020.1797369] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/24/2020] [Accepted: 07/10/2020] [Indexed: 12/13/2022] Open
Abstract
SARS-CoV-2, the virus causing COVID-19, is a single-stranded RNA virus belonging to the order Nidovirales, family Coronaviridae, and subfamily Coronavirinae. SARS-CoV-2 entry to cellsis initiated by the binding of the viral spike protein (S) to its cellular receptor. The roles of S protein in receptor binding and membrane fusion makes it a prominent target for vaccine development. SARS-CoV-2 genome sequence analysis has shown that this virus belongs to the beta-coronavirus genus, which includes Bat SARS-like coronavirus, SARS-CoV and MERS-CoV. A vaccine should induce a balanced immune response to elicit protective immunity. In this review, we compare and contrast these three important CoV diseases and how they inform on vaccine development.
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Affiliation(s)
| | - Wenli Sun
- Biotechnology Research Institute, Chinese Academy of Agricultural Sciences, Beijing, China
| | - Qi Cheng
- Biotechnology Research Institute, Chinese Academy of Agricultural Sciences, Beijing, China
- College of Life Sciences, Hebei Agricultural University, Baoding, Hebei, China
- Global Alliance of HeBAU-CLS&HeQiS for BioAl-Manufacturing, Baoding, Hebei, China
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Eke UA, Eke AC. Personal protective equipment in the siege of respiratory viral pandemics: strides made and next steps. Expert Rev Respir Med 2020; 15:441-452. [PMID: 33322947 DOI: 10.1080/17476348.2021.1865812] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Introduction: In December 2019, SARS-CoV-2 originated from China, and spread rapidly to several countries, bringing a frightening scarcity of personal protective equipment (PPE). The CDC recommends N95 or higher-level particulate filtering respirators as part of the PPE while caring for patients with COVID-19, with facemasks as an alternative; and cloth face-coverings in public where social distancing of at least 6 ft. is not feasible. With new evidence about the efficacy of facemasks, knowledge gaps remain.Areas covered: This reviews the history of respiratory viral pandemics and PPE use, exploring the influenza pandemics of the 20th and 21st century, and prior coronavirus pandemics. A literature search of PubMed and google was done between March 22nd to May 2nd, and on September 28, 2020. The evidence for PPE is described, to delineate their efficacy and 'best safe' practices. Solutions to ameliorate pandemic preparedness to meet surge-capacity to efficiently combat future pandemics, should they arise, are discussed.Expert opinion: PPE, when used appropriately in addition to other infection control measures, is effective protection during respiratory viral pandemics. The current evidence suggests that wearing facemasks in the community is protective, especially if used consistently and correctly with other infection control measures such as hand hygiene.
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Affiliation(s)
- Uzoamaka A Eke
- Division of Infectious Diseases and Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ahizechukwu C Eke
- Division of Maternal Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Analysis of the Healthcare MERS-CoV Outbreak in King Abdulaziz Medical Center, Riyadh, Saudi Arabia, June-August 2015 Using a SEIR Ward Transmission Model. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17082936. [PMID: 32340361 PMCID: PMC7215950 DOI: 10.3390/ijerph17082936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 12/28/2022]
Abstract
Middle East respiratory syndrome coronavirus (MERS-CoV) is an emerging zoonotic coronavirus that has a tendency to cause significant healthcare outbreaks among patients with serious comorbidities. We analyzed hospital data from the MERS-CoV outbreak in King Abdulaziz Medical Center, Riyadh, Saudi Arabia, June–August 2015 using the susceptible-exposed-infectious-recovered (SEIR) ward transmission model. The SEIR compartmental model considers several areas within the hospital where transmission occurred. We use a system of ordinary differential equations that incorporates the following units: emergency department (ED), out-patient clinic, intensive care unit, and hospital wards, where each area has its own carrying capacity and distinguishes the transmission by three individuals in the hospital: patients, health care workers (HCW), or mobile health care workers. The emergency department, as parameterized has a large influence over the epidemic size for both patients and health care workers. Trend of the basic reproduction number (R0), which reached a maximum of 1.39 at the peak of the epidemic and declined to 0.92 towards the end, shows that until added hospital controls are introduced, the outbreak would continue with sustained transmission between wards. Transmission rates where highest in the ED, and mobile HCWs were responsible for large part of the outbreak.
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Martins-Filho PR, de Gois-Santos VT, Tavares CSS, de Melo EGM, do Nascimento-Júnior EM, Santos VS. Recommendations for a safety dental care management during SARS-CoV-2 pandemic. Rev Panam Salud Publica 2020; 44:e51. [PMID: 32382259 PMCID: PMC7201058 DOI: 10.26633/rpsp.2020.51] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/10/2020] [Indexed: 12/20/2022] Open
Abstract
As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is transmitted mainly through droplets, sneezes and aerosols, there is a high risk of transmission during dental procedures. This report describes measures that can be adopted by oral healthcare personnel to minimize the risk of cross-contamination in clinical practice during the current SARS-CoV-2 pandemic.
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Affiliation(s)
- Paulo Ricardo Martins-Filho
- Federal University of Sergipe Federal University of Sergipe Sao Cristovao Brazil Federal University of Sergipe, Sao Cristovao, Brazil
| | - Vanessa Tavares de Gois-Santos
- Federal University of Sergipe Federal University of Sergipe Sao Cristovao Brazil Federal University of Sergipe, Sao Cristovao, Brazil
| | - Carolina Santos Souza Tavares
- Federal University of Sergipe Federal University of Sergipe Sao Cristovao Brazil Federal University of Sergipe, Sao Cristovao, Brazil
| | - Elisama Gomes Magalhães de Melo
- Federal University of Sergipe Federal University of Sergipe Sao Cristovao Brazil Federal University of Sergipe, Sao Cristovao, Brazil
| | | | - Victor Santana Santos
- Universidade Federal de Alagoas Universidade Federal de Alagoas Arapiraca Brazil Universidade Federal de Alagoas, Arapiraca, Brazil
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Al-Tawfiq JA, Rodriguez-Morales AJ. Super-spreading events and contribution to transmission of MERS, SARS, and SARS-CoV-2 (COVID-19). J Hosp Infect 2020; 105:111-112. [PMID: 32277963 PMCID: PMC7194732 DOI: 10.1016/j.jhin.2020.04.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 04/02/2020] [Indexed: 01/25/2023]
Affiliation(s)
- J A Al-Tawfiq
- Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - A J Rodriguez-Morales
- Public Health and Infection Research Group, Faculty of Health Sciences, Universidad Tecnologica de Pereira, Pereira, Risaralda, Colombia; Grupo de Investigación Biomedicina, Faculty of Medicine, Fundación Universitaria Autónoma de Las Américas, Pereira, Risaralda, Colombia
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Park J, Yoo SY, Ko JH, Lee SM, Chung YJ, Lee JH, Peck KR, Min JJ. Infection Prevention Measures for Surgical Procedures during a Middle East Respiratory Syndrome Outbreak in a Tertiary Care Hospital in South Korea. Sci Rep 2020; 10:325. [PMID: 31941957 PMCID: PMC6962363 DOI: 10.1038/s41598-019-57216-x] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/23/2019] [Indexed: 12/14/2022] Open
Abstract
In 2015, we experienced the largest in-hospital Middle East respiratory syndrome (MERS) outbreak outside the Arabian Peninsula. We share the infection prevention measures for surgical procedures during the unexpected outbreak at our hospital. We reviewed all forms of related documents and collected information through interviews with healthcare workers of our hospital. After the onset of outbreak, a multidisciplinary team devised institutional MERS-control guidelines. Two standard operating rooms were converted to temporary negative-pressure rooms by physically decreasing the inflow air volume (−4.7 Pa in the main room and −1.2 Pa in the anteroom). Healthcare workers were equipped with standard or enhanced personal protective equipment according to the MERS-related patient’s profile and symptoms. Six MERS-related patients underwent emergency surgery, including four MERS-exposed and two MERS-confirmed patients. Negative conversion of MERS-CoV polymerase chain reaction tests was noticed for MERS-confirmed patients before surgery. MERS-exposed patients were also tested twice preoperatively, all of which were negative. All operative procedures in MERS-related patients were performed without specific adverse events or perioperative MERS transmission. Our experience with setting up a temporary negative-pressure operation room and our conservative approach for managing MERS-related patients can be referred in cases of future unexpected MERS outbreaks in non-endemic countries.
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Affiliation(s)
- Jiyeon Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Yeon Yoo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Hoon Ko
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sangmin M Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Joo Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Jeong Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Adhikari U, Chabrelie A, Weir M, Boehnke K, McKenzie E, Ikner L, Wang M, Wang Q, Young K, Haas CN, Rose J, Mitchell J. A Case Study Evaluating the Risk of Infection from Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) in a Hospital Setting Through Bioaerosols. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2019; 39:2608-2624. [PMID: 31524301 PMCID: PMC7169172 DOI: 10.1111/risa.13389] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 05/15/2019] [Accepted: 06/24/2019] [Indexed: 05/03/2023]
Abstract
Middle Eastern respiratory syndrome, an emerging viral infection with a global case fatality rate of 35.5%, caused major outbreaks first in 2012 and 2015, though new cases are continuously reported around the world. Transmission is believed to mainly occur in healthcare settings through aerosolized particles. This study uses Quantitative Microbial Risk Assessment to develop a generalizable model that can assist with interpreting reported outbreak data or predict risk of infection with or without the recommended strategies. The exposure scenario includes a single index patient emitting virus-containing aerosols into the air by coughing, leading to short- and long-range airborne exposures for other patients in the same room, nurses, healthcare workers, and family visitors. Aerosol transport modeling was coupled with Monte Carlo simulation to evaluate the risk of MERS illness for the exposed population. Results from a typical scenario show the daily mean risk of infection to be the highest for the nurses and healthcare workers (8.49 × 10-4 and 7.91 × 10-4 , respectively), and the lowest for family visitors and patients staying in the same room (3.12 × 10-4 and 1.29 × 10-4 , respectively). Sensitivity analysis indicates that more than 90% of the uncertainty in the risk characterization is due to the viral concentration in saliva. Assessment of risk interventions showed that respiratory masks were found to have a greater effect in reducing the risks for all the groups evaluated (>90% risk reduction), while increasing the air exchange was effective for the other patients in the same room only (up to 58% risk reduction).
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Affiliation(s)
- Umesh Adhikari
- Department of Biosystems and Agricultural EngineeringMichigan State UniversityEast LansingMIUSA
| | - Alexandre Chabrelie
- Department of Biosystems and Agricultural EngineeringMichigan State UniversityEast LansingMIUSA
| | - Mark Weir
- Division of Environmental Health Sciences, College of Public HealthThe Ohio State UniversityColumbusOHUSA
| | - Kevin Boehnke
- Department of Anesthesiology & the Chronic Pain and Fatigue Research CenterUniversity of MichiganAnn ArborMIUSA
| | - Erica McKenzie
- Department of Civil and Environmental EngineeringTemple UniversityPhiladelphiaPAUSA
| | - Luisa Ikner
- Department of Soil, Water and Environmental ScienceUniversity of ArizonaTucsonAZUSA
| | - Meng Wang
- Department of Civil & Environmental EngineeringUniversity of South FloridaTampaFLUSA
| | - Qing Wang
- Department of Animal and Food SciencesUniversity of DelawareNewarkDEUSA
| | - Kyana Young
- Department of Fisheries and WildlifeMichigan State UniversityEast LansingMIUSA
| | - Charles N. Haas
- Department of Civil, Architectural and Environmental EngineeringDrexel UniversityPhiladelphiaPAUSA
| | - Joan Rose
- Department of Fisheries and WildlifeMichigan State UniversityEast LansingMIUSA
| | - Jade Mitchell
- Department of Biosystems and Agricultural EngineeringMichigan State UniversityEast LansingMIUSA
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Thompson RN, Stockwin JE, van Gaalen RD, Polonsky JA, Kamvar ZN, Demarsh PA, Dahlqwist E, Li S, Miguel E, Jombart T, Lessler J, Cauchemez S, Cori A. Improved inference of time-varying reproduction numbers during infectious disease outbreaks. Epidemics 2019; 29:100356. [PMID: 31624039 PMCID: PMC7105007 DOI: 10.1016/j.epidem.2019.100356] [Citation(s) in RCA: 244] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 02/07/2023] Open
Abstract
Accurate estimation of the parameters characterising infectious disease transmission is vital for optimising control interventions during epidemics. A valuable metric for assessing the current threat posed by an outbreak is the time-dependent reproduction number, i.e. the expected number of secondary cases caused by each infected individual. This quantity can be estimated using data on the numbers of observed new cases at successive times during an epidemic and the distribution of the serial interval (the time between symptomatic cases in a transmission chain). Some methods for estimating the reproduction number rely on pre-existing estimates of the serial interval distribution and assume that the entire outbreak is driven by local transmission. Here we show that accurate inference of current transmissibility, and the uncertainty associated with this estimate, requires: (i) up-to-date observations of the serial interval to be included, and; (ii) cases arising from local transmission to be distinguished from those imported from elsewhere. We demonstrate how pathogen transmissibility can be inferred appropriately using datasets from outbreaks of H1N1 influenza, Ebola virus disease and Middle-East Respiratory Syndrome. We present a tool for estimating the reproduction number in real-time during infectious disease outbreaks accurately, which is available as an R software package (EpiEstim 2.2). It is also accessible as an interactive, user-friendly online interface (EpiEstim App), permitting its use by non-specialists. Our tool is easy to apply for assessing the transmission potential, and hence informing control, during future outbreaks of a wide range of invading pathogens.
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Affiliation(s)
- R N Thompson
- Department of Zoology, University of Oxford, South Parks Road, Oxford OX1 3PS, UK; Mathematical Institute, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK; Christ Church, University of Oxford, St Aldates, Oxford OX1 1DP, UK.
| | - J E Stockwin
- Lady Margaret Hall, University of Oxford, Norham Gardens, Oxford OX2 6QA, UK
| | - R D van Gaalen
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), 3720 BA Bilthoven, the Netherlands
| | - J A Polonsky
- World Health Organization, Avenue Appia, Geneva 1202, Switzerland; Faculty of Medicine, University of Geneva, 1 Rue Michel-Servet, Geneva 1211, Switzerland
| | - Z N Kamvar
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, Faculty of Medicine, London W2 1PG, UK
| | - P A Demarsh
- The Surveillance Lab, McGill University, 1140 Pine Avenue West, Montreal H3A 1A3, Canada; Centre for Foodborne, Environmental and Zoonotic Infectious Diseases, Public Health Agency of Canada, 130 Colonnade Road, Ottawa, Ontario, K1A 0K9, Canada
| | - E Dahlqwist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - S Li
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - E Miguel
- MIVEGEC, IRD, University of Montpellier, CNRS, Montpellier, France
| | - T Jombart
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, Faculty of Medicine, London W2 1PG, UK; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - J Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - S Cauchemez
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, UMR2000, CNRS, Paris 75015, France
| | - A Cori
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, Faculty of Medicine, London W2 1PG, UK
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Bitely C, Miller B, Glauser J. EMS Disease Exposure, Transmission, and Prevention: a Review Article. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2019; 7:135-140. [PMID: 32226658 PMCID: PMC7100409 DOI: 10.1007/s40138-019-00200-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose of Review This article aims to review recent literature regarding the risks of disease exposure to pre-hospital providers and the patients they serve, as well as the challenges they face in minimizing transmission and exposure. Recent Findings Many studies continue to show poor compliance with consistent universal precautions, as well as proper hand hygiene. Vaccination rates are suboptimal despite attempts to encourage compliance. With the spread of multi-drug resistant organisms, new techniques of decontamination need to be investigated. Summary There remains a general lack of information and studies regarding the risks of disease exposure and transmission to EMS providers despite the significance hazards their profession can pose. However, there remains a continued theme throughout the majority of EMS and pre-hospital studies, demonstrating that hand washing and consistent use of personal protective equipment remains a persistent, preventable means of disease exposure and transmission.
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Affiliation(s)
- Colton Bitely
- Department of Emergency Medicine, MetroHealth Medical System, 2500 MetroHealth Drive, Cleveland, OH 44109 USA
| | - Brian Miller
- Department of Emergency Medicine, MetroHealth Medical System, 2500 MetroHealth Drive, Cleveland, OH 44109 USA
| | - Jonathan Glauser
- Department of Emergency Medicine, MetroHealth Medical System, 2500 MetroHealth Drive, Cleveland, OH 44109 USA
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Middle East respiratory syndrome coronavirus in the last two years: Health care workers still at risk. Am J Infect Control 2019; 47:1167-1170. [PMID: 31128983 PMCID: PMC7115296 DOI: 10.1016/j.ajic.2019.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND An important emerging respiratory virus is the Middle East respiratory syndrome coronavirus (MERS-CoV). MERS-CoV had been associated with a high case fatality rate especially among severe cases. METHODS This is a retrospective analysis of reported MERS-CoV cases between December 2016 and January 2019, as retrieved from the World Health Organization. The aim of this study is to examine the epidemiology of reported cases and quantify the percentage of health care workers (HCWs) among reported cases. RESULTS There were 403 reported cases with a majority being men (n = 300; 74.4%). These cases were reported from Lebanon, Malaysia, Oman, Qatar, Saudi Arabia, and United Arab Emirates. HCWs represented 26% and comorbidities were reported among 71% of non-HCWs and 1.9% among HCWs (P < .0001). Camel exposure and camel milk ingestion were reported in 64% each, and the majority (97.8%) of those with camel exposures had camel milk ingestion. There were 58% primary cases and 42% were secondary cases. The case fatality rate was 16% among HCWs compared with 34% among other patients (P = .001). The mean age ± SD was 47.65 ± 16.28 for HCWs versus 54.23 ± 17.34 for non-HCWs (P = .001). CONCLUSIONS MERS-CoV infection continues to have a high case fatality rate and a large proportion of patients were HCWs. Further understanding of the disease transmission and prevention mainly in health care settings are needed.
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Weber DJ, Sickbert-Bennett EE, Kanamori H, Rutala WA. New and emerging infectious diseases (Ebola, Middle Eastern respiratory syndrome coronavirus, carbapenem-resistant Enterobacteriaceae, Candida auris): Focus on environmental survival and germicide susceptibility. Am J Infect Control 2019; 47S:A29-A38. [PMID: 31146847 PMCID: PMC7132701 DOI: 10.1016/j.ajic.2019.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Al-Tawfiq JA, Abdrabalnabi R, Taher A, Mathew S, Rahman KA. Infection control influence of Middle East respiratory syndrome coronavirus: A hospital-based analysis. Am J Infect Control 2019; 47:431-434. [PMID: 30502108 PMCID: PMC7115328 DOI: 10.1016/j.ajic.2018.09.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 12/02/2022]
Abstract
BACKGROUND Middle East respiratory syndrome coronavirus (MERS-CoV) caused multiple outbreaks. Such outbreaks increase economic and infection control burdens. We studied the infection control influence of MERS-CoV using a hospital-based analysis. METHODS Our hospital had 17 positive and 82 negative cases of MERS-CoV between April 1, 2013, and June 3, 2013. The study evaluated the impact of these cases on the use of gloves, surgical masks, N95 respirators, alcohol-based hand sanitizer, and soap, as well as hand hygiene compliance rates. RESULTS During the study, the use of personal protective equipment during MERS-CoV compared with theperiod before MERS-CoV increased dramatically from 2,947.4 to 10,283.9 per 1,000 patient-days (P<.0000001) for surgical masks and from 22 to 232 per 1,000 patient-days (P <.0000001) for N95 masks. The use of alcohol-based hand sanitizer and soap showed a significant increase in utilized amount (P<.0000001). Hand hygiene compliance rates increased from 73% just before the occurrence of the first MERS case to 88% during MERS cases (P = .0001). The monthly added cost was $16,400 for included infection control items. CONCLUSIONS There was a significant increase in the utilization of surgical masks, respirators, soap and alcohol-based hand sanitizers. Such an increase is a challenge and adds cost to the healthcare system.
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Affiliation(s)
- Jaffar A Al-Tawfiq
- Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; Indiana University School of Medicine, Indianapolis, IN, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Rana Abdrabalnabi
- Infection Control Unit, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Alla Taher
- Infection Control Unit, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Shantymole Mathew
- Infection Control Unit, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Kamal Abdul Rahman
- Infection Control Unit, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
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Healthcare-associated infections: the hallmark of Middle East respiratory syndrome coronavirus with review of the literature. J Hosp Infect 2018; 101:20-29. [PMID: 29864486 PMCID: PMC7114594 DOI: 10.1016/j.jhin.2018.05.021] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 05/27/2018] [Indexed: 01/19/2023]
Abstract
Middle East respiratory syndrome coronavirus (MERS-CoV) is capable of causing acute respiratory illness. Laboratory-confirmed MERS-CoV cases may be asymptomatic, have mild disease, or have a life-threatening infection with a high case fatality rate. There are three patterns of transmission: sporadic community cases from presumed non-human exposure, family clusters arising from contact with an infected family index case, and healthcare-acquired infections among patients and from patients to healthcare workers. Healthcare-acquired MERS infection has become a well-known characteristic of the disease and a leading means of spread. The main factors contributing to healthcare-associated outbreaks include delayed recognition, inadequate infection control measures, inadequate triaging and isolation of suspected MERS or other respiratory illness patients, crowding, and patients remaining in the emergency department for many days. A review of the literature suggests that effective control of hospital outbreaks was accomplished in most instances by the application of proper infection control procedures. Prompt recognition, isolation and management of suspected cases are key factors for prevention of the spread of MERS. Repeated assessments of infection control and monitoring of corrective measures contribute to changing the course of an outbreak. Limiting the number of contacts and hospital visits are also important factors to decrease the spread of infection.
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Alenazi TH, Al Arbash H, El-Saed A, Alshamrani MM, Baffoe-Bonnie H, Arabi YM, Al Johani SM, Hijazi R, Alothman A, Balkhy HH. Identified Transmission Dynamics of Middle East Respiratory Syndrome Coronavirus Infection During an Outbreak: Implications of an Overcrowded Emergency Department. Clin Infect Dis 2018; 65:675-679. [PMID: 28575307 PMCID: PMC7108118 DOI: 10.1093/cid/cix352] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 04/26/2017] [Indexed: 12/14/2022] Open
Abstract
A total 130 cases of Middle East respiratory syndrome coronavirus were identified during a large hospital outbreak in Saudi Arabia; 87 patients and 43 healthcare workers. The majority (80%) of transmission was healthcare-acquired (HAI) infection, with 4 generations of HAI transmission. The emergency department was the main location of exposure.
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Affiliation(s)
- Thamer H Alenazi
- Infection Prevention and Control Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs.,King Saud Bin Abdulaziz University for Health Sciences
| | | | - Aiman El-Saed
- Infection Prevention and Control Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs.,King Saud Bin Abdulaziz University for Health Sciences
| | - Majid M Alshamrani
- Infection Prevention and Control Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs.,King Saud Bin Abdulaziz University for Health Sciences
| | - Henry Baffoe-Bonnie
- Infection Prevention and Control Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs
| | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences.,Intensive Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Sameera M Al Johani
- King Saud Bin Abdulaziz University for Health Sciences.,Department of Pathology, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ra'ed Hijazi
- Emergency Care Center, King Saud University, College of Medicine, Riyadh, Saudi Arabia
| | - Adel Alothman
- King Saud Bin Abdulaziz University for Health Sciences.,Division of Infectious Diseases, Depatment of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hanan H Balkhy
- Infection Prevention and Control Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs.,King Saud Bin Abdulaziz University for Health Sciences
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17
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O'Neil CA, Li J, Leavey A, Wang Y, Hink M, Wallace M, Biswas P, Burnham CAD, Babcock HM. Characterization of Aerosols Generated During Patient Care Activities. Clin Infect Dis 2018; 65:1335-1341. [PMID: 29017249 PMCID: PMC6248660 DOI: 10.1093/cid/cix535] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/16/2017] [Indexed: 12/16/2022] Open
Abstract
Background Questions remain about the degree to which aerosols are generated during routine patient care activities and whether such aerosols could transmit viable pathogens to healthcare personnel (HCP). The objective of this study was to measure aerosol production during multiple patient care activities and to examine the samples for bacterial pathogens. Methods Five aerosol characterization instruments were used to measure aerosols during 7 patient care activities: patient bathing, changing bed linens, pouring and flushing liquid waste, bronchoscopy, noninvasive ventilation, and nebulized medication administration (NMA). Each procedure was sampled 5 times. An SKC BioSampler was used for pathogen recovery. Bacterial cultures were performed on the sampling solution. Patients on contact precautions for drug-resistant organisms were selected for most activity sampling. Any patient undergoing bronchoscopy was eligible. Results Of 35 sampling episodes, only 2 procedures showed a significant increase in particle concentrations over baseline: NMA and bronchoscopy with NMA. Bronchoscopy without NMA and noninvasive ventilation did not generate significant aerosols. Of 78 cultures from the impinger samples, 6 of 28 baseline samples (21.4%) and 14 of 50 procedure samples (28.0%) were positive. Conclusions In this study, significant aerosol generation was only observed during NMA, both alone and during bronchoscopy. Minimal viable bacteria were recovered, mostly common environmental organisms. Although more research is needed, these data suggest that some of the procedures considered to be aerosol-generating may pose little infection risk to HCP.
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Affiliation(s)
- Caroline A O'Neil
- Infectious Diseases Division, Washington University School of Medicine, St Louis, MS
| | - Jiayu Li
- School of Engineering and Applied Science, Department of Energy, Environmental, and Chemical Engineering, Aerosol and Air Quality Research Laboratory, Washington University, St Louis, Missouri
| | - Anna Leavey
- School of Engineering and Applied Science, Department of Energy, Environmental, and Chemical Engineering, Aerosol and Air Quality Research Laboratory, Washington University, St Louis, Missouri
| | - Yang Wang
- School of Engineering and Applied Science, Department of Energy, Environmental, and Chemical Engineering, Aerosol and Air Quality Research Laboratory, Washington University, St Louis, Missouri
| | - Matthew Hink
- Infectious Diseases Division, Washington University School of Medicine, St Louis, MS
| | - Meghan Wallace
- School of Medicine, Department of Pathology and Immunology, Washington University, St Louis, Missouri
| | - Pratim Biswas
- School of Engineering and Applied Science, Department of Energy, Environmental, and Chemical Engineering, Aerosol and Air Quality Research Laboratory, Washington University, St Louis, Missouri
| | - Carey-Ann D Burnham
- School of Medicine, Department of Pathology and Immunology, Washington University, St Louis, Missouri
| | - Hilary M Babcock
- Infectious Diseases Division, Washington University School of Medicine, St Louis, MS
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MERS coronaviruses from camels in Africa exhibit region-dependent genetic diversity. Proc Natl Acad Sci U S A 2018; 115:3144-3149. [PMID: 29507189 PMCID: PMC5866576 DOI: 10.1073/pnas.1718769115] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Middle East respiratory syndrome (MERS) is a zoonotic disease of global health concern, and dromedary camels are the source of human infection. Although Africa has the largest number of dromedary camels, and MERS-coronavirus (MERS-CoV) is endemic in these camels, locally acquired zoonotic MERS is not reported from Africa. However, little is known of the genetic or phenotypic characterization of MERS-CoV from Africa. In this study we characterize MERS-CoV from Burkina Faso, Nigeria, Morocco, and Ethiopia. We demonstrate viral genetic and phenotypic differences in viruses from West Africa, which may be relevant to differences in zoonotic potential, highlighting the need for studies of MERS-CoV at the animal–human interface. Middle East respiratory syndrome coronavirus (MERS-CoV) causes a zoonotic respiratory disease of global public health concern, and dromedary camels are the only proven source of zoonotic infection. Although MERS-CoV infection is ubiquitous in dromedaries across Africa as well as in the Arabian Peninsula, zoonotic disease appears confined to the Arabian Peninsula. MERS-CoVs from Africa have hitherto been poorly studied. We genetically and phenotypically characterized MERS-CoV from dromedaries sampled in Morocco, Burkina Faso, Nigeria, and Ethiopia. Viruses from Africa (clade C) are phylogenetically distinct from contemporary viruses from the Arabian Peninsula (clades A and B) but remain antigenically similar in microneutralization tests. Viruses from West (Nigeria, Burkina Faso) and North (Morocco) Africa form a subclade, C1, that shares clade-defining genetic signatures including deletions in the accessory gene ORF4b. Compared with human and camel MERS-CoV from Saudi Arabia, virus isolates from Burkina Faso (BF785) and Nigeria (Nig1657) had lower virus replication competence in Calu-3 cells and in ex vivo cultures of human bronchus and lung. BF785 replicated to lower titer in lungs of human DPP4-transduced mice. A reverse genetics-derived recombinant MERS-CoV (EMC) lacking ORF4b elicited higher type I and III IFN responses than the isogenic EMC virus in Calu-3 cells. However, ORF4b deletions may not be the major determinant of the reduced replication competence of BF785 and Nig1657. Genetic and phenotypic differences in West African viruses may be relevant to zoonotic potential. There is an urgent need for studies of MERS-CoV at the animal–human interface.
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Al-Tawfiq JA, Rothwell S, Mcgregor HA, Khouri ZA. A multi-faceted approach of a nursing led education in response to MERS-CoV infection. J Infect Public Health 2018; 11:260-264. [PMID: 28869153 PMCID: PMC7102837 DOI: 10.1016/j.jiph.2017.08.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 08/04/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The emergence of the Middle East respiratory syndrome-coronavirus (MERS-CoV) resulted in multiple healthcare associated outbreaks. In response, we developed a nurse-led program to screen and triage patients with MERS-CoV infection. METHODS A formal educational program was implemented to ensure a standardized approach to care planning and delivery. The essential skills that were included were the use of Personal Protective Equipment (PPE) including gown, gloves, head cover and N95 mask, hand hygiene, the practice of donning and doffing and the collection of MERS-CoV nasopharyngeal specimens. RESULTS A core group of nurses were identified from high-risk units. The education program consisted of four skill-days. Nurses were assigned a pre-course work from Mosby's Nursing Skills, an online skill module, donning and doffing of PPE, and the process for obtaining a nasopharyngeal swab. The skill lab incorporated multiple methods such group discussion, watching an on-line video, and a simulated demonstration and practice on a mannequin. In total, 450 nurses attended the Nasopharyngeal Skills Day and 1000 nurses received training. Donning and doffing PPE and N95 mask fit testing has become an annual mandatory competency requirement for staff in nursing and clinical services. CONCLUSION The application of specified protocols minimizes the risks of cross infection, placing emphasis on patient and staff safety as well as expediting the patient to definitive treatment. Nurse educators have an instrumental role in training nurses and other healthcare providers on the specifics needed to identify, contain and manage patient presenting with MERS-CoV.
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Affiliation(s)
- Jaffar A Al-Tawfiq
- Specaility Medicine Division, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Siobhan Rothwell
- Nursing Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Heather A Mcgregor
- Nursing Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Zeina A Khouri
- Nursing Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
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20
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Al-Tawfiq JA, Rabaan AA, Hinedi K. Influenza is more common than Middle East Respiratory Syndrome Coronavirus (MERS-CoV) among hospitalized adult Saudi patients. Travel Med Infect Dis 2017; 20:56-60. [PMID: 29031867 PMCID: PMC7110697 DOI: 10.1016/j.tmaid.2017.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/08/2017] [Accepted: 10/09/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Since the initial description of Middle East Respiratory Syndrome Coronavirus (MERS-CoV), we adopted a systematic process of screening patients admitted with community acquired pneumonia. Here, we report the result of the surveillance activity in a general hospital in Saudi Arabia over a four year period. MATERIALS AND METHODS All admitted patients with community acquired pneumonia from 2012 to 2016 were tested for MERS-CoV. In addition, testing for influenza viruses was carried out starting April 2015. RESULTS During the study period, a total of 2657 patients were screened for MERS-CoV and only 20 (0.74%) tested positive. From January 2015 to December 2016, a total of 1644 patients were tested for both MERS-CoV and influenza. None of the patients tested positive for MERS-CoV and 271 (16.4%) were positive for influenza. The detected influenza viruses were Influenza A (107, 6.5%), pandemic 2009 H1N1 (n = 120, 7.3%), and Influenza B (n = 44, 2.7%). Pandemic H1N1 was the most common influenza in 2015 with a peak in peaked October to December and influenza A other than H1N1 was more common in 2016 with a peak in August and then October to December. CONCLUSIONS MERS-CoV was a rare cause of community acquired pneumonia and other viral causes including influenza were much more common. Thus, admitted patients are potentially manageable with Oseltamivir or Zanamivir therapy.
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Affiliation(s)
- Jaffar A Al-Tawfiq
- Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Ali A Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Kareem Hinedi
- Division of Hospital Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
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21
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Rabaan AA, Al-Ahmed SH, Bazzi AM, Al-Tawfiq JA. Dynamics of scientific publications on the MERS-CoV outbreaks in Saudi Arabia. J Infect Public Health 2017. [PMID: 28625842 PMCID: PMC7102777 DOI: 10.1016/j.jiph.2017.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is an emerging disease with a relatively high case fatality rate. Most cases have been reported from Saudi Arabia, and the disease epidemic potential is considered to be limited. However, human-human transmission has occurred, usually in the context of healthcare facility-associated outbreaks. The scientific and medical community depends on timely publication of epidemiological information on emerging diseases during outbreaks to appropriately target public health responses. In this review, we considered the academic response to four MERS CoV outbreaks that occurred in Al-Hasa in 2013, Jeddah in 2014 and Riyadh in 2014 and 2015. We analysed 68 relevant epidemiology articles. For articles for which submission dates were available, six articles were submitted during the course of an outbreak. One article was published within a month of the Al-Hasa outbreak, and one each was accepted during the Jeddah and Riyadh outbreaks. MERS-CoV epidemiology articles were cited more frequently than articles on other subjects in the same journal issues. Thus, most epidemiology articles on MERS-CoV were published with no preferential advantage over other articles. Collaboration of the research community and the scientific publishing industry is needed to facilitate timely publication of emerging infectious diseases.
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Affiliation(s)
- Ali A Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Shamsah H Al-Ahmed
- Specialty Paediatric Medicine, Qatif Central Hospital, Qatif, Saudi Arabia
| | - Ali M Bazzi
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Jaffar A Al-Tawfiq
- Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; Indiana University School of Medicine, Indianapolis, IN, USA.
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22
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Al-Tawfiq JA, Memish ZA. Update on therapeutic options for Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Expert Rev Anti Infect Ther 2016; 15:269-275. [PMID: 27937060 PMCID: PMC7103731 DOI: 10.1080/14787210.2017.1271712] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is an important emerging respiratory pathogen. MERS-CoV resulted in multiple hospital outbreaks within and outside the Arabian Peninsula. The disease has a high case fatality rate, with the need for a therapeutic option. Areas covered: In this review, we provide an overview of the progress in the development of therapeutic strategies for MERS. We searched PubMed, Embase, Cochrane, Scopus, and Google Scholar, using the following terms: 'MERS', 'MERS-CoV', 'Middle East respiratory syndrome' in combination with 'treatment' or 'therapy'. Expert commentary: There are multiple agents tried in vitro and in vivo. None of these agents were used in large clinical studies. Available clinical studies are limited to the use of the combination of interferon and other agents. These clinical studies are based solely on case reports and case series. There are no prospective or randomized trials. There is a need to have prospective and randomized clinical trials for the therapy of MERS-CoV. However, this strategy might be hampered by the sporadic cases outside the large hospital outbreaks.
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Affiliation(s)
- Jaffar A Al-Tawfiq
- a Specialty Internal Medicine , Johns Hopkins Aramco Healthcare , Dhahran , Kingdom of Saudi Arabia.,b Department of Medicine , Indiana University School of Medicine , Indianapolis , IN , USA
| | - Ziad A Memish
- c Department of Medicine , Ministry of Health , Riyadh , Kingdom of Saudi Arabia.,d Hubert Department of Global Health, Rollins School of Public Health , Emory University , Atlanta , GA , USA
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23
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Abstract
Emergence of many emerging or re-emerging infectious diseases have occurred over the past decade, some of which are major public threat. SARS, MERS-CoV, highly pathogenic avian influenza A(H5N1), Ebola virus disease have raised concerns because of their virulence, their mortality, and/or their modality of transmission, or their impact on maternofoetal transmission (Zika virus). The witness of these emergences have conducted health authorities to have policies and plans and to imagine new organizations for health systems in order to identify any case of highly communicable virulent disease for immediate isolation, and adequate management.
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Affiliation(s)
- C Chidiac
- Service des maladies infectieuses et tropicales, hospices civils de Lyon, GHN, CIRI U1111, hôpital de la Croix-Rousse, université Claude-Bernard Lyon 1, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France.
| | - T Ferry
- Service des maladies infectieuses et tropicales, hospices civils de Lyon, GHN, CIRI U1111, hôpital de la Croix-Rousse, université Claude-Bernard Lyon 1, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
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24
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Kim CJ, Choi WS, Jung Y, Kiem S, Seol HY, Woo HJ, Choi YH, Son JS, Kim KH, Kim YS, Kim ES, Park SH, Yoon JH, Choi SM, Lee H, Oh WS, Choi SY, Kim NJ, Choi JP, Park SY, Kim J, Jeong SJ, Lee KS, Jang HC, Rhee JY, Kim BN, Bang JH, Lee JH, Park S, Kim HY, Choi JK, Wi YM, Choi HJ. Surveillance of the Middle East respiratory syndrome (MERS) coronavirus (CoV) infection in healthcare workers after contact with confirmed MERS patients: incidence and risk factors of MERS-CoV seropositivity. Clin Microbiol Infect 2016; 22:880-886. [PMID: 27475739 PMCID: PMC7128923 DOI: 10.1016/j.cmi.2016.07.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 07/11/2016] [Accepted: 07/16/2016] [Indexed: 01/16/2023]
Abstract
Given the mode of transmission of Middle East respiratory syndrome (MERS), healthcare workers (HCWs) in contact with MERS patients are expected to be at risk of MERS infections. We evaluated the prevalence of MERS coronavirus (CoV) immunoglobulin (Ig) G in HCWs exposed to MERS patients and calculated the incidence of MERS-affected cases in HCWs. We enrolled HCWs from hospitals where confirmed MERS patients had visited. Serum was collected 4 to 6 weeks after the last contact with a confirmed MERS patient. We performed an enzyme-linked immunosorbent assay (ELISA) to screen for the presence of MERS-CoV IgG and an indirect immunofluorescence test (IIFT) to confirm MERS-CoV IgG. We used a questionnaire to collect information regarding the exposure. We calculated the incidence of MERS-affected cases by dividing the sum of PCR-confirmed and serology-confirmed cases by the number of exposed HCWs in participating hospitals. In total, 1169 HCWs in 31 hospitals had contact with 114 MERS patients, and among the HCWs, 15 were PCR-confirmed MERS cases in study hospitals. Serologic analysis was performed for 737 participants. ELISA was positive in five participants and borderline for seven. IIFT was positive for two (0.3%) of these 12 participants. Among the participants who did not use appropriate personal protective equipment (PPE), seropositivity was 0.7% (2/294) compared to 0% (0/443) in cases with appropriate PPE use. The incidence of MERS infection in HCWs was 1.5% (17/1169). The seroprevalence of MERS-CoV IgG among HCWs was higher among participants who did not use appropriate PPE.
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Affiliation(s)
- C-J Kim
- Department of Internal Medicine, Division of Infectious Diseases, Ewha Womans University School of Medicine, South Korea
| | - W S Choi
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Y Jung
- Department of Internal Medicine, Konyang University Hospital, South Korea
| | - S Kiem
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, South Korea
| | - H Y Seol
- Department of Internal Medicine, Good GangAn Hospital, South Korea
| | - H J Woo
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, South Korea
| | - Y H Choi
- Department of Internal Medicine, Ajou University Hospital, South Korea
| | - J S Son
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, South Korea
| | - K-H Kim
- Department of Internal Medicine, Pusan National University Hospital, South Korea
| | - Y-S Kim
- Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University School of Medicine, South Korea
| | - E S Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, South Korea
| | - S H Park
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Daejeon St. Mary's Hospital, South Korea
| | - J H Yoon
- Department of Internal Medicine, Eulji University Hospital, South Korea
| | - S-M Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Yeouido St. Mary's Hospital, South Korea
| | - H Lee
- Division of Infectious Diseases, Dong-A University Hospital, South Korea
| | - W S Oh
- Department of Internal Medicine, Kangwon National University Hospital, South Korea
| | - S-Y Choi
- Department of Neurology, Dae Cheong Hospital, South Korea
| | - N-J Kim
- Department of Internal Medicine, Seoul National University Hospital, South Korea
| | - J-P Choi
- Department of Internal Medicine, Seoul Medical Center, South Korea
| | - S Y Park
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, South Korea
| | - J Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, South Korea
| | - S J Jeong
- Department of Internal Medicine, Gangnam Severance Hospital, South Korea
| | - K S Lee
- Department of Internal Medicine, Myongji Hospital, South Korea
| | - H C Jang
- Department of Internal Medicine, Chonnam National University Hospital, South Korea
| | - J Y Rhee
- Department of Internal Medicine, Dankook University Hospital, South Korea
| | - B-N Kim
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, South Korea
| | - J H Bang
- Department of Internal Medicine, Borame Medical Center, South Korea
| | - J H Lee
- Department of Internal Medicine, Wonkwang University Hospital, South Korea
| | - S Park
- Department of Family Medicine, Seobuk Hospital Seoul Metropolitan Government, South Korea
| | - H Y Kim
- Department of Internal Medicine, Wonju Severance Christian Hospital, South Korea
| | - J K Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital, South Korea
| | - Y-M Wi
- Department of Internal Medicine, Samsung Changwon Hospital, South Korea
| | - H J Choi
- Department of Internal Medicine, Division of Infectious Diseases, Ewha Womans University School of Medicine, South Korea.
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Description of a Hospital Outbreak of Middle East Respiratory Syndrome in a Large Tertiary Care Hospital in Saudi Arabia. Infect Control Hosp Epidemiol 2016; 37:1147-55. [PMID: 27426423 PMCID: PMC7113028 DOI: 10.1017/ice.2016.132] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Since the first isolation of Middle East respiratory syndrome coronavirus (MERS-CoV) in Saudi Arabia in 2012, sporadic cases, clusters, and sometimes large outbreaks have been reported. OBJECTIVE To describe the recent (2015) MERS-CoV outbreak at a large tertiary care hospital in Riyadh, Saudi Arabia. METHODS We conducted an epidemiologic outbreak investigation, including case finding and contact tracing and screening. MERS-CoV cases were categorized as suspected, probable, and confirmed. A confirmed case was defined as positive reverse transcription polymerase chain reaction test for MERS-CoV. RESULTS Of the 130 suspected cases, 81 (62%) were confirmed and 49 (38%) were probable. These included 87 patients (67%) and 43 healthcare workers (33%). Older age (mean [SD], 64.4 [18.3] vs 40.1 [11.3] years, P<.001), symptoms (97% vs 58%, P<.001), and comorbidity (99% vs 42%, P<.001) were more common in patients than healthcare workers. Almost all patients (97%) were hospitalized whereas most healthcare workers (72%) were home isolated. Among 96 hospitalized cases, 63 (66%) required intensive care unit management and 60 (63%) required mechanical ventilation. Among all 130 cases, 51 (39%) died; all were patients (51 [59%]) with no deaths among healthcare workers. More than half (54%) of infections were believed to be caught at the emergency department. Strict infection control measures, including isolation and closure of the emergency department, were implemented to interrupt the chain of transmission and end the outbreak. CONCLUSION MERS-CoV remains a major healthcare threat. Early recognition of cases and rapid implementation of infection control measures are necessary. Infect Control Hosp Epidemiol 2016;1–9
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Park MH, Kim HR, Choi DH, Sung JH, Kim JH. Emergency cesarean section in an epidemic of the middle east respiratory syndrome: a case report. Korean J Anesthesiol 2016; 69:287-91. [PMID: 27274377 PMCID: PMC4891544 DOI: 10.4097/kjae.2016.69.3.287] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 08/19/2015] [Accepted: 08/25/2015] [Indexed: 11/10/2022] Open
Abstract
Only a few reports have been published on women with an infectious respiratory viral pathogen, such as Middle East Respiratory Syndrome (MERS) Coronavirus delivering a baby. A laboratory confirmed case of MERS was reported during a MERS outbreak in the Republic of Korea in a woman at gestational week 35 + 4. She recovered, and delivered a healthy baby by emergency cesarean section (C-sec). We present the clinical course and the emergency C-sec in a pregnant woman with MERS.
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Affiliation(s)
- Mi Hye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunwan University School of Medicne, Seoul, Korea
| | - Hee Ryun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunwan University School of Medicne, Seoul, Korea
| | - Duck Hwan Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunwan University School of Medicne, Seoul, Korea
| | - Ji Hee Sung
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunwan University School of Medicne, Seoul, Korea
| | - Jong Hwa Kim
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunwan University School of Medicne, Seoul, Korea
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Weber DJ, Rutala WA, Fischer WA, Kanamori H, Sickbert-Bennett EE. Emerging infectious diseases: Focus on infection control issues for novel coronaviruses (Severe Acute Respiratory Syndrome-CoV and Middle East Respiratory Syndrome-CoV), hemorrhagic fever viruses (Lassa and Ebola), and highly pathogenic avian influenza viruses, A(H5N1) and A(H7N9). Am J Infect Control 2016; 44:e91-e100. [PMID: 27131142 PMCID: PMC7132650 DOI: 10.1016/j.ajic.2015.11.018] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 11/11/2015] [Indexed: 01/01/2023]
Abstract
Over the past several decades, we have witnessed the emergence of many new infectious agents, some of which are major public threats. New and emerging infectious diseases which are both transmissible from patient-to-patient and virulent with a high mortality include novel coronaviruses (SARS-CoV, MERS-CV), hemorrhagic fever viruses (Lassa, Ebola), and highly pathogenic avian influenza A viruses, A(H5N1) and A(H7N9). All healthcare facilities need to have policies and plans in place for early identification of patients with a highly communicable diseases which are highly virulent, ability to immediately isolate such patients, and provide proper management (e.g., training and availability of personal protective equipment) to prevent transmission to healthcare personnel, other patients and visitors to the healthcare facility.
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Affiliation(s)
- David J Weber
- Department of Hospital Epidemiology, University of North Carolina Health Care, Chapel Hill, NC; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - William A Rutala
- Department of Hospital Epidemiology, University of North Carolina Health Care, Chapel Hill, NC; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC
| | - William A Fischer
- Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Hajime Kanamori
- Department of Hospital Epidemiology, University of North Carolina Health Care, Chapel Hill, NC; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Emily E Sickbert-Bennett
- Department of Hospital Epidemiology, University of North Carolina Health Care, Chapel Hill, NC; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC
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Abstract
Middle East respiratory Syndrome Coronavirus (MERS-CoV) has caused at least 1118 reported cases in 24 countries with at least 423 deaths worldwide. All cases are epidemiologically linked to the Arabian Penninsula with most cases reported from the Kingdom of Saudi Arabia. MERS-CoV has three patterns of presentation: sporadic isolated cases, small clusters of intra-familial transmission and large healthcare-associated infections. The disease presentation varies from asymptomatic/mild cases to severe and fatal cases. The source of the virus has focused on bats and dromedary camels but the exact mode of disease transmission continues to be debated. Current data indicate that the virus spreads from human to human through droplet and contact routes, while performing aerosole-generating procedures predispose to airborne transmission. The best diagnostic tests rely on the identification of MERS-CoV by PCR, and lower respiratory tract samples should be favoured for the diagnosis whenever this is possible in order to avoid false negative results. Recently, the World Health Organization added serology to the list of confirmatory tests. Currently, there is no proven therapy, with supportive treatment being the mainstay of treatment.
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29
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Al-Tawfiq JA, Memish ZA. Infection control measures for the prevention of MERS coronavirus transmission in healthcare settings. Expert Rev Anti Infect Ther 2016; 14:281-3. [PMID: 26687211 DOI: 10.1586/14787210.2016.1135053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Jaffar A Al-Tawfiq
- a Department of Medicine , Johns Hopkins Aramco Healthcare , Dhahran , Kingdom of Saudi Arabia.,b Department of Medicine , Indiana University School of Medicine , Indianapolis , IN , USA
| | - Ziad A Memish
- c Ministry of Health, College of Medicine , Alfaisal University , Riyadh , Kingdom of Saudi Arabia
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30
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Al-Tawfiq JA, Memish ZA. Drivers of MERS-CoV transmission: what do we know? Expert Rev Respir Med 2016; 10:331-8. [PMID: 26848513 PMCID: PMC7103679 DOI: 10.1586/17476348.2016.1150784] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 02/02/2016] [Indexed: 12/14/2022]
Abstract
Middle East Respiratory Syndrome coronavirus (MERS-CoV) emerged in 2012 has since resulted in sporadic cases, intra-familial transmission and major outbreaks in healthcare settings. The clinical picture of MERS-CoV includes asymptomatic infections, mild or moderately symptomatic cases and fatal disease. Transmissions of MERS-CoV within healthcare settings are facilitated by overcrowding, poor compliance with basic infection control measures, unrecognized infections, the superspreaders phenomenon and poor triage systems. The actual contributing factors to the spread of MERS-CoV are yet to be systematically studied, but data to date suggest viral, host and environmental factors play a major role. Here, we summarize the known factors for the diverse transmission of MERS-CoV.
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Affiliation(s)
- Jaffar A. Al-Tawfiq
- Medical Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ziad A. Memish
- Medical Department, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Kingdom of Saudi Arabia
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31
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Kim KM, Ki M, Cho SI, Sung M, Hong JK, Cheong HK, Kim JH, Lee SE, Lee C, Lee KJ, Park YS, Kim SW, Choi BY. Epidemiologic features of the first MERS outbreak in Korea: focus on Pyeongtaek St. Mary's Hospital. Epidemiol Health 2015; 37:e2015041. [PMID: 26725225 PMCID: PMC4652064 DOI: 10.4178/epih/e2015041] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/17/2015] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES: This study investigated the epidemiologic features of the confirmed cases of Middle East Respiratory Syndrome (MERS) in Pyeongtaek St. Mary’s Hospital, where the outbreak first began, in order to identify lessons relevant for the prevention and control of future outbreaks. METHODS: The patients’ clinical symptoms and test results were collected from their medical records. The caregivers of patients were identified by phone calls. RESULTS: After patient zero (case #1) was admitted to Pyeongtaek St. Mary’s Hospital (May 15-May 17), an outbreak occurred, with 36 cases between May 18 and June 4, 2015. Six patients died (fatality rate, 16.7%). Twenty-six cases occurred in the first-generation, and 10 in the second-generation. The median incubation period was five days, while the median period from symptom onset to death was 12.5 days. While the total attack rate was 3.9%, the attack rate among inpatients was 7.6%, and the inpatients on the eighth floor, where patient zero was hospitalized, had an 18.6% attack rate. In contrast, caregivers and medical staff showed attack rates of 3.3% and 1.1%, respectively. CONCLUSIONS: The attack rates were higher than those of the previous outbreaks in other countries. The outbreak spread beyond Pyeongtaek St. Mary’s Hospital when four of the patients were moved to other hospitals without appropriate quarantine. The best method of preventing future outbreaks is to overcome the vulnerabilities observed in this outbreak, such as ward crowding, patient migration without appropriate data sharing, and the lack of an initial broad quarantine.
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Affiliation(s)
- Kyung Min Kim
- Division of Epidemic Intelligence Service, Korea Centers for Disease Control and Prevention, Cheongju, Korea
| | - Moran Ki
- Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
| | - Sung-Il Cho
- Graduate School of Public Health and Institute of Health and Environment, Seoul National University, Seoul, Korea
| | - Minki Sung
- Department of Architectural Engineering, Sejong University, Seoul, Korea
| | - Jin Kwan Hong
- Department of HVAC & Firefighting Engineering, Gachon University College of Engineering, Seongnam, Korea
| | - Hae-Kwan Cheong
- Department of Social and Preventive Medicine, Sungkyunkwan University School of Medicine, Suwon, Korea
| | - Jong-Hun Kim
- Department of Social and Preventive Medicine, Sungkyunkwan University School of Medicine, Suwon, Korea
| | - Sang-Eun Lee
- Division of Malaria and Parasitic Diseases, Korea Centers for Disease Control and Prevention, Cheongju, Korea
| | - Changhwan Lee
- Division of Epidemic Intelligence Service, Korea Centers for Disease Control and Prevention, Cheongju, Korea
| | - Keon-Joo Lee
- Division of Epidemic Intelligence Service, Korea Centers for Disease Control and Prevention, Cheongju, Korea
| | - Yong-Shik Park
- Division of Epidemic Intelligence Service, Korea Centers for Disease Control and Prevention, Cheongju, Korea
| | - Seung Woo Kim
- Division of Epidemic Intelligence Service, Korea Centers for Disease Control and Prevention, Cheongju, Korea
| | - Bo Youl Choi
- Department of Preventive Medicine, Hanyang University College of Medicine, Seoul, Korea
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32
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Abstract
The distinct characteristic of the Middle East Respiratory Syndrome (MERS) outbreak in South Korea is that it not only involves intra-hospital transmission, but it also involves hospital-to-hospital transmission. It has been the largest MERS outbreak outside the Middle East, with 186 confirmed cases and, among them, 36 fatal cases as of July 26, 2015. All confirmed cases are suspected to be hospital-acquired infections except one case of household transmission and two cases still undergoing examination. The Korean health care system has been the major factor shaping the unique characteristics of the outbreak. Taking this as an opportunity, the Korean government should carefully assess the fundamental problems of the vulnerability to hospital infection and make short- as well as long-term plans for countermeasures. In addition, it is hoped that this journal, Epidemiology and Health, becomes a place where various topics regarding MERS can be discussed and shared.
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Affiliation(s)
- Moran Ki
- Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
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33
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Memish ZA, Al-Tawfiq JA, Alhakeem RF, Assiri A, Alharby KD, Almahallawi MS, Alkhallawi M. Middle East respiratory syndrome coronavirus (MERS-CoV): A cluster analysis with implications for global management of suspected cases. Travel Med Infect Dis 2015; 13:311-4. [PMID: 26211569 PMCID: PMC7110629 DOI: 10.1016/j.tmaid.2015.06.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 06/27/2015] [Accepted: 06/29/2015] [Indexed: 01/02/2023]
Abstract
Since the initial description of the Middle East respiratory syndrome (MERS) in September 2012, a total of 1038 cases of MERS-CoV including 460 deaths have been reported from Saudi Arabia. From August 24, 2013 to September 3, 2013, a total of 397 patients and contacts were tested for MERS-CoV. Of those tested, there were 18 (4.5%) MERS-CoV cases reported in Al-Madinah al-Munawwarah with one large cluster. In this report, we describe the outcome, epidemiology and clinical characteristics of this cluster of which 4 cases involved healthcare workers. Fourteen cases appeared to be linked to one cluster involving healthcare workers (HCWs), family and patient contacts. Of the 18 cases, five (including 2 HCWs) were community acquired, two were household contacts, and 11 were healthcare associated (including 4 HCWs). All except 4 cases were symptomatic and the case fatality rate was 39% (7 of 18). The outbreak resulted in human to human transmission of an estimated 6 cases. Contact screening showed positive test in 1 of 56 (1.8%) household contacts, and 3 of 250 (1.2%) HCWs.
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Affiliation(s)
- Ziad A Memish
- Ministry of Health, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Jaffar A Al-Tawfiq
- Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; Indiana University School of Medicine, Indianapolis, IN, USA.
| | | | | | - Khalid D Alharby
- Regional Health Directorate, Ministry of Health, Madinah, Saudi Arabia
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