More MERS in 3 Saudi cities as WHO recaps mission

Saudi Arabia reported four more MERS-CoV cases in the past 3 days, two of them likely linked to an outbreak in Medina, and the World Health Organization (WHO) yesterday issued a statement on a recent mission to probe a large hospital outbreak in Riyadh.

A WHO emergency committee earlier this month raised concerns about circulation of the virus as more than 2 million pilgrims are gathering in Saudi Arabia for the Hajj pilgrimage, considered the world's largest mass gathering.

Though MERS-CoV (Middle East respiratory syndrome coronavirus) activity seems to be slowing some in an outbreak in Riyadh, new infections are popping up in some of the country's other major cities, such as Jeddah—a primary arrival spot for international travelers—and Medina, one of the country's major holy sites.

Pace slows in Riyadh, but cases noted elsewhere

The pace of new cases from Riyadh over the past week seems to have slowed but has done so amid signals of possible hospital-related outbreaks in Medina and Najran. Announcements from the Saudi Arabia Ministry of Health (MOH) over the last few days hint at another similar event in Jeddah, which involved a sick healthcare worker whose exposure to a previous case is under review.

Medina's two new cases were reported by the MOH yesterday and today, bringing to seven the number of cases reported in the city—the second holiest in Saudi Arabia—this month. One involves a foreign healthcare worker, a 34-year-old woman who is hospitalized in stable condition. Health officials are still exploring if she had earlier contact with a suspected or confirmed case.

Three of the seven cases reported this month so far in Medina involved healthcare workers.

The other case reported in Medina is in a 30-year-old Saudi man who his hospitalized in critical condition. Authorities are also still exploring his source of infection.

The sick healthcare worker from Jeddah is a 24-year-old foreign woman who is listed in critical condition. Officials are still trying to determine how she contracted the virus. The woman's illness is the first MERS-CoV case reported from Jeddah since early April.

Meanwhile, the one case in Riyadh involves a 71-year-old Saudi woman who is hospitalized in stable condition. The Saudi MOH said the woman didn't have contact with an earlier case.

Twenty more people have recovered from their infections over the past 3 days, and as of today, 44 people are still being treated for their MERS-CoV infections. Also, an additional 13 people are in home isolation.

Two more earlier announced patients died from their illnesses, a 58-year-old Saudi woman and 60-year-old Saudi man. Both were from Riyadh and had underlying medical conditions.

The latest developments lift Saudi Arabia's total from the disease to 1,235 cases, which includes 523 deaths.

WHO weighs in on Riyadh mission

The WHO's Eastern Mediterranean regional office yesterday issued a statement on a recent expert mission to investigate a large hospital outbreak in Riyadh. WHO experts visited Riyadh on Aug 23, and its initial findings informed the WHO's MERS emergency committee, which met for the 10th time on Sep 2 to discuss the latest developments.

The emergency committee held off on declaring a global health emergency then, but in a strongly worded statement raised major concerns about Saudi Arabia's efforts to curb the threat. It criticized the nation for not following its earlier recommendations, including having a lack of routine reporting of asymptomatic cases, which are thought to play a role in fueling MERS-CoV activity.

In its statement yesterday, the WHO said experts met with Saudi MOH officials and toured emergency and isolation facilities at the Riyadh outbreak hospital, King Abdulaziz Medical City. The agency also said it assessed the situation at Prince Mohammed bin Abdulaziz Hospital in Riyadh, one of the country's three national reference centers for the disease. WHO officials have said a smaller outbreak occurred at a second hospital but was quickly contained. It's not clear if Prince Mohammed bin Abdulaziz is that second hospital.

The WHO said 112 cases with links to the main outbreak hospital were reported from the first week of July until Aug 31. Thirty-eight of those cases proved fatal.

Most of the cases linked to the hospital outbreak, which is still ongoing, involved patient-to-patient transmission, according to the WHO. Other factors included emergency department (ED) overcrowding and breaches in infection-control measures by some patients, visitors, and healthcare workers.

WHO experts learned of no multiple transmission chains in the ED of the main outbreak hospital or in any other Riyadh hospitals that received patients who were exposed at King Adbulaziz Medical City. It said the Saudi MOH was still investigating how transmission occurred and possible risk factors, such as length of stay in the ED and movements of ED patients to other parts of the hospital.

Though the WHO commended the Saudi MOH for its steps to contain the outbreak, it urged officials to regularly share more information with it on control steps and outbreak status. It said the hospital outbreak serves an example that even small lapses in infection control and prevention practices can spark a large outbreak, posing a risk not only to Saudi Arabia but to other countries, as well.

Experts also developed a set of recommendations, including documenting the lessons learned in battling the outbreak, strengthening infection control practices in all of the country's health systems, involving the agriculture ministry in the prevention and investigation of community-acquired cases, and filling in and sharing the results of scientific and epidemiologic knowledge gaps about MERS-CoV.

Hospital fined

In other developments, Riyadh health officials have fined a private hospital $27,000 for its lapses in handling a MERS-CoV patient, Arab News reported yesterday. It said the patient was forced to go to another hospital, where his or her infection was confirmed.

Authorities said the unnamed facility did not handle a MERS patient according to practices required by the MOH, according to the report, which also said national health officials have launched an intensive campaign to raise awareness about the disease.

Antibody response tracked

On the science front, researchers from South Korea and Hong Kong late last week reported new serologic findings, based on 17 patients who underwent treatment at three hospitals in South Korea—two in Seoul and one in Bundang. The team reported its findings in a Sep 11 early online edition of Emerging Infectious Diseases.

The investigators examined the patients' serologic responses with virus neutralization and ELISA tests. Of the 17 patients, 9 had severe infections and 8 had mild disease. One patient died.

Most patients mounted a robust antibody response by the third week of illness, and delayed response as measured by the neutralization test was associated with more severe infections, the team found.

See also:

Sep 12 Saudi MOH statement

Sep 13 Saudi MOH statement

Sep 14 Saudi MOH statement

Sep 13 WHO MERS mission statement

Sep 3 CIDRAP News story "Panel says no MERS emergency amid rising concerns"

Sep 13 Arab News story

Sep 11 Emerg Infect Dis report

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