Infection control and MERS-CoV in health-care workers
2014; Elsevier BV; Volume: 383; Issue: 9932 Linguagem: Inglês
10.1016/s0140-6736(14)60852-7
ISSN1474-547X
AutoresAlimuddin Zumla, David S.C. Hui,
Tópico(s)SARS-CoV-2 and COVID-19 Research
ResumoThe recent exponential rise in the number of reported cases of Middle East respiratory syndrome coronavirus (MERS-CoV) is of major global concern. The Fifth Meeting of the International Health Regulations Emergency Committee concerning MERS-CoV was convened on May 13, 2014, by WHO's Director-General and concluded that, although the seriousness of the situation had increased, there was no evidence of sustained human-to-human transmission and that conditions for a Public Health Emergency of International Concern have not yet been met.1WHOWHO statement on the Fifth Meeting of the IHR Emergency Committee concerning MERS-CoV.http://www.who.int/mediacentre/news/statements/2014/mers-20140514/en/Date: May 14, 2014Google Scholar MERS-CoV was first reported in September, 2012, when a novel β coronavirus was isolated from a Saudi Arabian patient in Jeddah, who had died of severe pneumonia and multiple organ failure in June, 2012.2Zaki AM van Boheemen S Bestebroer TM et al.Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia.N Engl J Med. 2012; 367: 1814-1820Crossref PubMed Scopus (4187) Google Scholar More recently, a large number of MERS-CoV cases have been reported from Saudi Arabia and for the first time cases have been detected in Malaysia, Philippines, Greece, Egypt, Netherlands, and the USA. There have been a total of 572 cases of MERS-CoV infection reported to WHO globally as of May 15, 2014, with 173 deaths (30% mortality rate).3WHOGlobal alert and response. Middle East respiratory syndrome coronavirus (MERS-CoV)—update.http://www.who.int/csr/don/2014_05_15_mers/en/Date: May 15, 2014Google Scholar The large number of MERS-CoV cases (229 cases) reported between April 11, 2014, and May 4, 2014, by Saudi Arabia were probably seasonal (related to the camel birthing season), reminiscent of the clusters of hospital cases that were previously confirmed in a hospital in Jordan in April, 2012,4Hijawi B Abdallat M Sayaydeh A et al.Novel coronavirus infections in Jordan, April 2012: epidemiological findings from a retrospective investigation.East Mediterr Health J. 2013; 19: S12-S18PubMed Google Scholar which involved haemodialysis units within hospitals in Al Hasa in April and May, 2013.5Assiri A McGeer A Perl TM et al.Hospital outbreak of Middle East respiratory syndrome coronavirus.N Engl J Med. 2013; 369: 407-416Crossref PubMed Scopus (947) Google Scholar Sequencing of the MERS-CoV isolates from the Jeddah outbreak has shown no substantial genetic changes.1WHOWHO statement on the Fifth Meeting of the IHR Emergency Committee concerning MERS-CoV.http://www.who.int/mediacentre/news/statements/2014/mers-20140514/en/Date: May 14, 2014Google Scholar The WHO Emergency Committee concluded that the increase in cases reported among health-care workers from hospitals in Jeddah was amplified due to overcrowding and inadequate infection control measures.1WHOWHO statement on the Fifth Meeting of the IHR Emergency Committee concerning MERS-CoV.http://www.who.int/mediacentre/news/statements/2014/mers-20140514/en/Date: May 14, 2014Google Scholar, 3WHOGlobal alert and response. Middle East respiratory syndrome coronavirus (MERS-CoV)—update.http://www.who.int/csr/don/2014_05_15_mers/en/Date: May 15, 2014Google Scholar Acute viral respiratory tract infections, such as severe acute respiratory syndrome (SARS) and MERS, are predominantly spread by large respiratory droplets (≥10 μm in diameter) during coughing and sneezing, whereas contact with fomite (including hand contamination with subsequent self-inoculation) might be another potential route of transmission.6Hui DS Memish ZA Zumla A Severe acute respiratory syndrome vs the Middle East respiratory syndrome.Curr Opin Pulm Med. 2014; 20: 233-241Crossref PubMed Scopus (169) Google Scholar, 7Seto WH Conly JM Pessoa-Silva CL Malik M Eremin S Infection prevention and control measures for acute respiratory infections in healthcare settings: an update.East Mediterr Health J. 2013; 19: S39-47PubMed Google Scholar The SARS outbreak in 2003 provided good lessons for the evaluation of environmental influences on the aerosol transmission of communicable respiratory diseases and the importance of good infection control measures in the prevention of nosocomial infections. One intriguing aspect of the 2003 SARS epidemic was the occurrence of super-spreading events, which accounted for 71·1% and 74·8% of SARS cases in Hong Kong and Singapore, respectively.8Riley S Fraser C Donnelly CA et al.Transmission dynamics of the etiological agent of SARS in Hong Kong: impact of public health interventions.Science. 2003; 300: 1961-1966Crossref PubMed Scopus (885) Google Scholar During the SARS outbreak in 2003, SARS-coronavirus (CoV) was moderately transmissible, with 2·7 secondary infections for every index case.8Riley S Fraser C Donnelly CA et al.Transmission dynamics of the etiological agent of SARS in Hong Kong: impact of public health interventions.Science. 2003; 300: 1961-1966Crossref PubMed Scopus (885) Google Scholar However, infectivity was substantially increased when coupled with environmental factors: 138 patients, many of whom were health-care workers, were infected within 2 weeks as a result of exposure to one patient with community-acquired pneumonia who was admitted to a general medical ward.9Lee N Hui DS Wu A et al.A major outbreak of severe acute respiratory syndrome in Hong Kong.N Engl J Med. 2003; 348: 1986-1994Crossref PubMed Scopus (1982) Google Scholar This super-spreading event seemed to be related to overcrowding and poor ventilation in the dry air-conditioned hospital ward, together with some contribution by the use of a jet nebuliser for the index case.10Tomlinson B Cockram C SARS: experience at Prince of Wales Hospital, Hong Kong.Lancet. 2003; 361: 1486-1487Summary Full Text Full Text PDF PubMed Scopus (133) Google Scholar Evidence of airborne transmission of SARS-CoV was also supported by positive air samples of the virus obtained from a hospital room occupied by a patient with SARS in Toronto, Canada.11Booth TF Kournikakis B Bastien N et al.Detection of airborne severe acute respiratory syndrome (SARS) coronavirus and environmental contamination in SARS outbreak units.J Infect Dis. 2005; 191: 1472-1477Crossref PubMed Scopus (341) Google Scholar On the basis of analysis of data in a case-control study that involved 124 medical wards in 26 hospitals in Guangzhou, China, and Hong Kong, the risk factors for super-spreading events of SARS-CoV in the hospital setting were: close separation between beds of less than 1 m; performance of resuscitation; staff working while experiencing symptoms; and patients requiring oxygen or non-invasive ventilation therapy.12Yu IT Xie ZH Tsoi KK et al.Why did outbreaks of severe acute respiratory syndrome occur in some hospital wards but not in others?.Clin Infect Dis. 2007; 44: 1017-1025Crossref PubMed Scopus (148) Google Scholar This study also showed that the availability of washing or changing facilities for health-care staff was a protective factor.12Yu IT Xie ZH Tsoi KK et al.Why did outbreaks of severe acute respiratory syndrome occur in some hospital wards but not in others?.Clin Infect Dis. 2007; 44: 1017-1025Crossref PubMed Scopus (148) Google Scholar These findings have important clinical implications in the prevention of nosocomial infections of MERS-CoV in health-care facilities in the Middle East. A systematic review of five case-control and five retrospective cohort studies identified tracheal intubation, tracheotomy, and manual ventilation before intubation as procedures associated with risk of transmission of SARS-CoV to health-care workers.13Tran K Cimon K Severn M Pessoa-Silva CL Conly J Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review.PLoS One. 2012; 7: e35797Crossref PubMed Scopus (1322) Google Scholar Opportunistic airborne transmission might occur through fine particle aerosols as an efficient means of propagation under special environmental conditions, such as with aerosol-generating procedures in a ward environment with poor ventilation and insufficient air changes.7Seto WH Conly JM Pessoa-Silva CL Malik M Eremin S Infection prevention and control measures for acute respiratory infections in healthcare settings: an update.East Mediterr Health J. 2013; 19: S39-47PubMed Google Scholar The main infection prevention and control measures for managing acute viral respiratory tract infections are simple and well documented: droplet precaution (wearing a surgical mask within 1 m of the patient) and contact precaution (wearing gown and gloves on entering the room and removing them on leaving).14Siegel JD Rhinehart E Jackson M Chiarello L the Healthcare Infection Control Practices Advisory Committee2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. 2007.http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.htmlGoogle Scholar Droplet precautions should be added to standard precautions for patients with symptoms of acute respiratory infection. Contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection. Airborne precautions should be applied when performing aerosol-generating procedures.3WHOGlobal alert and response. Middle East respiratory syndrome coronavirus (MERS-CoV)—update.http://www.who.int/csr/don/2014_05_15_mers/en/Date: May 15, 2014Google Scholar, 6Hui DS Memish ZA Zumla A Severe acute respiratory syndrome vs the Middle East respiratory syndrome.Curr Opin Pulm Med. 2014; 20: 233-241Crossref PubMed Scopus (169) Google Scholar, 7Seto WH Conly JM Pessoa-Silva CL Malik M Eremin S Infection prevention and control measures for acute respiratory infections in healthcare settings: an update.East Mediterr Health J. 2013; 19: S39-47PubMed Google Scholar, 15CDCInterim infection prevention and control recommendations for hospitalized patients with Middle East respiratory syndrome coronavirus (MERS-CoV).http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html#infection-preventionDate: May 15, 2014Google Scholar To reduce room contamination in the hospital setting, major health organisations have recommended the application of a minimum room ventilation rate of six air changes per hour in existing facility, whereas a higher ventilation rate of 12 air changes per hour is recommended for new or renovated construction, especially when caring for patients receiving mechanical ventilation and during aerosol-generating procedures.16WHOWHO guidelines on natural ventilation for infection control in health-care settings. World Health Organization, Geneva2009http://whqlibdoc.who.int/publications/2009/9789241547857_eng.pdfGoogle Scholar, 17Sehulster L Chinn RY CDCHICPACGuidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).MMWR Recomm Rep. 2003; 52: 1-42PubMed Google Scholar Infection source and engineering control, including avoidance of aerosol generation with appropriate airborne precautions, and improvement of ventilation design in hospital wards warrant serious consideration for the prevention of nosocomial outbreaks. The MERS-CoV outbreak in Jeddah, and the increasing number of health-care workers acquiring the infection as a result of poor infection control measures, remind us of the need to go back to the basics of infection control to help prevent MERS-CoV infection in health-care workers. This online publication has been corrected. The corrected version first appeared at thelancet.com on May 21, 2014 This online publication has been corrected. The corrected version first appeared at thelancet.com on May 21, 2014 AZ and DSH serve on the Scientific Advisory Committee of the Saudi Ministry of Health Global Centre for Mass Gathering Medicine. We declare no competing interests. Department of ErrorZumla A, Hui DS. Infection control and MERS-CoV in health-care workers. Lancet 2014; published online May 20. http://dx.doi.org/10.1016/S0140-6736(14)60852-7—In this Comment, reference 8 should refer to Riley S et al and reference 9 should refer to Lee N et al. In the fourth paragraph reference 8 should be cited at the end of the fourth sentence and reference 9 should be cited at the end of the fifth sentence. This correction has been made to the online version as of May 21, 2014. Full-Text PDF
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