Case definition and management of patients with MERS coronavirus in Saudi Arabia

Exponential increases in the number of cases of the Middle East respiratory syndrome coronavirus (MERS-CoV) in Saudi Arabia in March, 2014,¹ led to the appointment of Adel Fakeih as acting Minister of Health on April 21, 2014. He made the control of the MERS outbreak a top priority in the country's health agenda. An advisory council was set up to urgently develop scientific evidence-based plans to control the MERS outbreak and prevent human-to-human and animal-to-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 effectively 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; capacity-building 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 extra-corporeal 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 and control measures in health-care facilities including King Fahd General Hospital, Jeddah, where substantial health-care–associated transmission of MERS-CoV between patients and staff happened, mainly due to overcrowding of patients by about four to five times its maximum capacity in the emergency room. Overflow patients in the emergency room were relocated to other hospitals in Jeddah to reduce the risk of further transmission of the virus. Intensive education and training of staff about essential infection control measures were done to abort transmission of MERS-CoV in health-care settings. The MOH has also invited experts from WHO and the US Centers for Disease Control and Prevention (CDC) to assess the outbreak. The advisory council, in collaboration with the CDC, has initiated case-control studies to identify risk factors for acquisition of MERS-CoV infection in primary and secondary cases.

As new clinical information became available, a revision of the MERS-CoV case definition seemed appropriate.² The new case definition (appendix) was developed based on reported health-care-associated MERS-CoV pneumonia (added as category 2 in the new case definition) and non-respiratory characteristics of patients with confirmed infection who first presented with acute febrile dengue-like illness with body aches, leucopenia, and thrombocytopenia (added as category 3). The new case definition 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 definition classified the status of patients into three categories of suspect, probable, or confirmed infection. The new MERS-CoV case definition was revised and approved by the advisory council after seeking external CDC expert opinion.

An algorithm for MERS-CoV case management was developed (figure ). According to this algorithm, patients with confirmed MERS-CoV who have no evidence of pneumonia or who recover from pneumonia 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

Figure.

Management algorithm for patients suspected of MERS coronavirus infection

CD=case definition. SOB=shortness of breath. *Patients with suspected MERS-CoV infection who do not have shortness of breath, hypoxaemia, or evidence of pneumonia can be cared for and isolated in their home (if suitable).