Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

sharon sanders · Sep 12, 2013

Thursday, 12 September 2013

Middle East respiratory syndrome coronavirus cases amongst healthcare workers [UPDATED]

</td></tr> <tr><td class="tr-caption" style="text-align: center;">Click on image to enlarge. (a) the proportion of
MERS-CoV positives HCWs who have died (red) vs.
survived (blue), (b) the proportion of fatal cases (PFC; red)
of MERS-CoV worldwide vs. the proportion of
surviving cases (PSC; blue) (c) breakdown HCWs
as a proportion of all MERS-CoV cases (blue), HCW deaths
as a proportion of all MERS cases (green) and HCW deaths
as a proportion of all MERS-CoV deaths.</td></tr> </tbody></table> With a lot of help from FluTrackers, the 2 of us have synced our lists to account for all the healthcare workers (HCWs) for which public data are available, that have been confirmed as MERS-CoV positive.

Some charts then.

We can see that HCWs make up approximately a sixth (18.2%; n=24) of all MERS-CoV cases.

Fatal infections in HCWs account for 2.3% (3/132) of all MERS-CoV cases (including living and deceased cases) and 5.4% of all MERS-CoV deaths worldwide are among HCWs (3/56). This last figure indicates that HCWs are at a relatively reduced risk of death from MERS-CoV infection when compared to other groups that have been infected.

For example:
NB: I have death data for 56 cases; age data for 125/132 cases; sex data for 120/132 cases); 27 comorbidities listed [underestimate]

63% of MERS-CoV deaths have occurred among those older than 55-years (50% of deaths among those >60-years; 38% among those >65-years; 59% among those <65-years)
46% of MERS-CoV deaths have occurred among males older than 55-years (38% among those>69-years; 30% among those >65-years; 45% among those <65-years)
82% of deaths )n=46) and 83% of cases have occurred in the Kingdom of Saudi Arabia
48% of MERS-CoV deaths occurred among those with comorbidities [this is an underestimate]So in the lower proportion of deaths represented by HCWs, while horrible in any proportion, may provide evidence to support that MERS-CoV is still not transmitting well, even in close quarters.

It may also mean that attending HCWs are adhering to good infection control and prevention practices. But it coudl just mean that we do not have data on all HCW infections/death and there are greater numbers of cases.

Finally, and perhaps most importantly, we should remember that HCWs may have some degree of resistance to disease caused by some viruses because of their constant exposure to patients with all manner of airway infections.

If HCWs may not show the same proportion of illness, but still become infected, they can act to spread cases among their contacts - patients and visitors. This was evident in the severe acute respiratory syndrome (SARS) outbreak where HCWs accounted for a fifth of all confirmed cases.<sup>1</sup>

In other words, even a few cases in HCWs could have major implications for nosocomial outbreaks. If an emerging virus, such as the MERS-CoV, is being frequently detected in association with healthcare settings, that scenario may already be happening.

Some literature..

Posted by Ian M Mackay

sharon sanders · Sep 12, 2013

Re: Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

The Saudi Ministry of Health has not released any information about some nCoV coronavirus death cases in the past. Their number of deaths is higher than the number on our list (which we have disclosed for some time) because we can not link some deaths to any particular case. I think this discrepancy is about 3 or 4.

In addition, there are media reports of deaths that are not substantiated by the Ministry of Health. It is difficult to quantify these. A few:

1) Man, 55, with kidney failure, hospitalized in ICU - Medina, Madinah province, Saudi Arabia (SA83) - media reports his death, not MoH confirmed,

2) Turkey - Media report of 5 Saudi citizens suspected nCoV coronavirus - 1 possible death, 3 evacuated to Saudi Arabia - Trabzon - September 7, 2013,

3) Saudi Arabia - Media report that a hospital doctor, 67, died September 5 of nCoV coronavirus in Medina

4) Man, 51, hospitalized January 30, co-morbidities of cancer and diabetes, died February 24, brother of cases 15 & 16 - Riyadh - Saudi Arabia

Laidback Al · Sep 12, 2013

Re: Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

For more than 70% of the MERS-CoV confirmed cases there is no information available on the occupation of the infected individuals. It is not possible to speculate on the source of infection for these individuals. However, the infection among health care workers in most instances, and perhaps all, resulted from human-to-human transmission.

To date, at least 23 of the confirmed MERS-CoV cases have been identified as health care workers, 18 from Saudi Arabia, 4 from the United Arab Emirates, and 1 from Jordan (see attached table). The lack of transparency from the Kingdom of Saudi Arabia, makes interpreting these cases difficult. There is at least one current media report of a nosocomial outbreak in Riyadh that has been denied by public health officials (link).

In addition to these confirmed cases, 9 of the 13 cases in the original Al Zarqa outbreak in Jordan in 2012 were health care workers. They are reported as probable cases so they are not counted in the current list of MERS-CoV confirmed cases (link). In general, these data indicated that health care workers are at great infection risk from this novel coronavirus.

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sharon sanders · Sep 12, 2013

Re: Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

Thanks Al. We have the 2 symptomatic health care cases listed on the June 26th WHO report in the range of cases #71-#77:

"#71-#77 - No details - 7 more cases announced, possibly 6 asymptomatic, ages 7 - 15, plus a person age 50 from the Eastern province - Saudi Arabia"

I will add the notation of 2 health care workers. Apparently the difference is between the Saudi MoH report which did not list them as health care workers and the WHO report several days later.

:tiphat:

IanM · Sep 13, 2013

Re: Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

What about #119?

sharon sanders · Sep 13, 2013

Re: Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

This is the list of health care workers that I constructed yesterday morning from our main nCoV coronavirus list:

http://www.flutrackers.com/forum/showpost.php?p=509330&postcount=3

My list is consistent with WHO. I made a change after I saw Al's list above by changing from MoH designations to WHO data. Some cases at the MoH level have never been identified as health care workers. To be consistent I selected to use WHO updated data.

I have 23 health care workers on my list.

As to case #62: This case has never been announced at any official level as a health care worker. There are a couple of media reports mentioning this doctor by name. See our thread here.

If I include this doctor on our official list then what about the other media articles about health care workers? Aren't they just as important? What about all of the nurses in the media reports?

So to be consistent, I am not designating any case on our list as a health care worker unless this person has been designated as such by either the MoH or WHO, with WHO taking the lead if there is a disparity.

The probables/suspected/mentions are listed on our case list but not numbered. See my list referenced above.

This all goes to the larger question, What is the level of risk for health care workers in this situation?

I say it is high. I am sure we are missing cases. I think that generally young people tolerate this infection better than adults and I think that there are probably many asymptomatic cases. No matter what precautions are taken by any health care facility, it is not enough against an asymptomatic disease with no acknowledged cause.

Health care workers should take precautions against this disease. Health care facilities should employ strict infection control protocols.

And the Saudi government should not allow camel sacrifices this Hajj because one confirmed case in the Al Batin cluster was reported to be in contact with a sick camel and camels in Oman and Egypt have tested positive for coronavirus.

Giuseppe · Sep 13, 2013

Re: Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

[Source: Epidemic, full page: (LINK). Excerpt.]

Rough Analysis of MERS-CoV case data to date

by Andrew Rambaut on Fri, 2013-09-13 15:37
____

This analysis is done using the case data presented on this page. The same caveats on that page applies - the data is rough, gleaned from various sources both official and not and contains errors and omissions. The conclusions here are conditional on these data and should not be consider anything bit indicative of possible trends. This page was prompted by some discussion on by Helen Branswell [@HelenBranswell], Ian Mackay [@MackayIM], [@FluTrackers] and others on Twitter. It was also motivated by two, widely made, observations.

(?)

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sharon sanders · Sep 13, 2013

Re: Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

from the above blog:

"It seems unlikely that people with chronic illness have a greater exposure to a source of infection than the wider public so either they are at greater risk of infection per exposure or it is only the severe cases that are being diagnosed and there is a large tail of mild and asymptomatic cases."

I think only the severe cases are being diagnosed and/or reported because they are so clinically ill, and therefore, there is a large tail of mild and asymptomatic cases.

We have seen this effect in the past, for instance in Indonesia 2012 here and here. It appears the only cases reported were deaths. Either H5N1 in Indonesia is 100% fatal (or nearly) or, the bulk of the cases are unreported.

Biological · Sep 13, 2013

Re: Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

Hypothesis ver 1.0 cases described in Table 1

(use with caution++)

Pt 1 ? Case 40/ age 43/42 Al-Hufuf , Al-Ahsa? (HCW-Nurse administrator, at cardiac arrest)
Pt 2 ? Case 68 Taif?
Pt 3 ? Case 66 Taif?
pt 4 ? Case 67 Taif?
pt 5 unknown (?75) Al-Ahsa ??
pt 6 unknown (?76) Eastern Province??
pt 7 ? Case 80 Hafr Al-Batin?

Memish ZA, Zumla AI, Assiri A. Middle East respiratory syndrome coronavirus infections in health care workers. (Letter) N Engl J Med 2013 (early online publication Aug 7) 2013DOI: 10.1056/NEJMc1308698

http://www.nejm.org/doi/pdf/10.1056/NEJMc1308698

http://www.nejm.org/doi/suppl/10.1056/NEJMc1308698/suppl_file/nejmc1308698_appendix.pdf

Trying to match cases but inconclusive case mete data results!

sharon sanders · Sep 13, 2013

Re: Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

Biological said:
Hypothesis ver 1.0 cases described in Table 1

(use with caution++)

Pt 1 ? Case 40/ age 43/42 Al-Hufuf , Al-Ahsa? (HCW-Nurse administrator, at cardiac arrest)
Pt 2 ? Case 68 Taif?
Pt 3 ? Case 66 Taif?
pt 4 ? Case 67 Taif?
pt 5 unknown (?75) Al-Ahsa ??
pt 6 unknown (?76) Eastern Province??
pt 7 ? Case 80 Hafr Al-Batin?

Memish ZA, Zumla AI, Assiri A. Middle East respiratory syndrome coronavirus infections in health care workers. (Letter) N Engl J Med 2013 (early online publication Aug 7) 2013DOI: 10.1056/NEJMc1308698

http://www.nejm.org/doi/pdf/10.1056/NEJMc1308698

http://www.nejm.org/doi/suppl/10.1056/NEJMc1308698/suppl_file/nejmc1308698_appendix.pdf

Trying to match cases but inconclusive case mete data results!

--------------------------------

These are my guesses from our case list based on WHO/MoH announced cases:

Patient 1 - possible cases:

#65 - Woman, 42, recovered - Eastern province - Saudi Arabia

#84 - Woman, 42, health care worker - mild case, not hospitized - Asir province - Saudi Arabia

Patient 2 - possible cases:

#68 - Woman, 29, health care worker in Taif, Mecca province - Saudi Arabia

Patient 3 - possible cases:

None, might be a case not reported or sex/age on this study is incorrect?

Patient 4 - possible cases:

#67 - Woman, 39, health care worker in Taif, Mecca province - Saudi Arabia

#93 - Woman, 39, health care worker - Asir province - Saudi Arabia

Patient 5 - possible cases:

None, might be a case not reported or sex/age on this study is incorrect?

Patient 6 - possible cases:

None, might be a case not reported or sex/age on this study is incorrect?

sharon sanders · Sep 14, 2013

Re: Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

I have talked to Mike Coston and Ian Mackay at length and we think that the value that FluTrackers can add here is the fact that our main case list is a baseline of WHO/MoH announced cases.

People can add other cases via research papers, media reports etc. For example, Andrew Rambaut has compiled a list that adds quite a few cases to the WHO/MoH baseline.

But somewhere there needs to be one list that has a concrete base. And our list is that.

As far as the above speculation goes trying to match up the patient descriptions in the NEJM paper to WHO/MoH announced cases, it seems difficult.

Is it really possible that the Saudi Deputy Minister of Health would co-write a paper about nCoV coronavirus in health care workers and not announce some of those cases on the Ministry of Health site?

Giuseppe · Sep 14, 2013

Re: Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

Some doubts are pressing MoH, see - for example - this new update:

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Source: Saudi Arabia Ministry of Health, http://www.moh.gov.sa/Ministry/MediaCenter/News/Pages/News-2013-09-14-002.aspx - In Arabic, automatic translation.

(Sept 14 2013)

Rabia Hassan confirms to deal with patients and caring for their demands

He stressed the Minister of Health. Abdullah bin Abdulaziz Al-Rabiah on the importance of dealing Hassan with the patient and beneficiaries of the services of the ministry stressed the need to adhere to the principles of transparency, honesty and credibility, and activated a method and values and constants are going by the Ministry of Health.

His Excellency said that it is our duty employees of the Ministry and especially health practitioners attention to the demands of the patient is on the right always and that the basics of health work and ethics Out of the Secretariat entrusted to us must stand with the patient and work hard to meet the needs of the health service and provide medical care for him.

This came during Ma'aleh yesterday chaired the third periodic meeting of ministry officials and directors of health affairs and provincial areas and held meetings at the Diwan Hall of the ministry.

The Minister stressed the importance of activating the ministry's logo (the patient first) and the obligation to be implemented in all sectors of the ministry facilities. Stressing the need to focus on quality and safety programs, medicine and patient care to earn patient satisfaction and service.

Ma'aleh urged everyone on the importance of continuing to pursue the principle of collective institutional work and consolidate a culture of quality among all workers in the ministry, facilities, so as to contribute positively to the development of health services and improving performance levels ministry facilities.

Have been discussed during the meeting a number of issues related to improving the performance of health facilities and the development of services provided to citizens were also reviewed the functioning of the software quality service implemented by the Ministry as well as access to health projects currently implemented and what has been achieved so far and to review the latest developments for the coronavirus regionally and internationally, and efforts to address it and limit its spread.

The meeting was attended by Vice Minister of the Ministry agents and general managers in addition to the directors of health affairs and provincial areas.

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Biological · Sep 14, 2013

Re: Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

I also agree with that above post.. One of difficulties I encountered matching the HCW's/cases was not only age differences, location but onset dates , hospitalisations, etc...

Ver 1.0 was only 6 cases of HCW's which I could only speculate so my attempt was futile but earlier when I attempted to apply many journal articles my "no data" became more data!

Real time data "time of reporting" is only the initial phase of the investigations when looking in from a far!

Forgetting the possibilities of just healthcare workers and looking at cases as well matching Journal articles with cases I feel is important because it gives a different picture once the investigations have been investigated by reputable sources and international researchers..

When matching/comparing many different line lists, graphs, gant charts from Flu trackers, ECDC, RKI, WHO Manila, Philippines, , Flu Wiki, VDU etc and my own developed through KSA, MOH/WHO reports and assistance from the latter!

I always find "time of reporting" case listings are in the infant stage of review and supporting journal articles are definitely important to fine tune case listings mete data!

Matching journal articles, is the last stage in the process because these are the follow up investigations of initial outbreak notification mete data... I believe it is important to bare in mind I have encountered some you can so-called "match" or update and others you can only speculate!

MOH KSA members and the investigational team which includes reputable professionals from internationally outbreak teams etc including WHO, CDC, PHAC,ECDC, HPA,RKI Universities etc co-authoring journal articles gives just another reputable view of case mete data..

Flutrackers forum have done a fantastic job in collating the information in a line list, posts etc however the investigational research from journal article I believe is one of the final pieces of the puzzle that if missed takes away from the time and hard work already given by public/professional arena's in posting here or anywhere!

I realise this site is for notification as per say like ProMed or any other blogging site!

I assume everyone uses Flu trackers for different purposes!

I've use it for my personal MERS CoV research / line list and matching cases only serves my personal interest in creating a line list that is supported with up to date mete data by reputable references!

Analysis: Middle East respiratory syndrome coronavirus cases amongst healthcare workers using Saudi MoH data - September 12, 2013

sharon sanders

Editor-in-Chief & President

sharon sanders

Editor-in-Chief & President

Laidback Al

Well-known member

sharon sanders

Editor-in-Chief & President

IanM

Member

sharon sanders

Editor-in-Chief & President

Giuseppe

Emeritus

sharon sanders

Editor-in-Chief & President

Biological

Closed. Please see Biological100

sharon sanders

Editor-in-Chief & President

sharon sanders

Editor-in-Chief & President

Giuseppe

Emeritus

Biological

Closed. Please see Biological100