As more foreign-borne illnesses enter the U.S., such as the two patients with Ebola who were treated at Emory University Hospital and confirmed cases of mosquito-carried Dengue fever, new infection control protocols are top of mind for U.S. hospitals.
Although Ebola is currently of critical concern, U.S. hospitals should also be prepared for the potential high-risk exposure to the MERS-CoV virus during the upcoming Hajj pilgrimage with an increase of persons traveling to and from Saudi Arabia. The Hajj will take place October 3-6 this year, and every year, over ten thousand U.S. residents participate in the Hajj pilgrimage. The millions of pilgrims traveling, worshipping and staying in accommodations with large groups will significantly increase the risk of MERS transmission among pilgrims and the possibility of bringing the virus back to their home countries, potentially causing widespread global distribution.
Middle East Respiratory Syndrome is a viral respiratory illness first reported in Saudi Arabia in 2012. Caused by a coronavirus called MERS-CoV, the infection presents as a severe acute respiratory illness including fever, cough and shortness of breath. Unfortunately, about 45 percent of people confirmed to have the MERS-CoV infection have died. Although the illness has been regionalized thus far, it will be become increasingly more important for the U.S. to expand options for rapid diagnostic testing for more efficient screening of high-risk persons. In addition to more efficient screening, new infection control protocols and better population tracking will also need to be considered in both hospital and outpatient settings.
Global issue, local action
As of May 28, 2014, 636 laboratory-confirmed cases of infection with MERS-CoV have officially been reported to the World Health Organization, including 193 deaths. Several clusters of cases associated with healthcare facilities have been reported and are thought to represent nosocomial transmission. Standard precautions including hand washing, respiratory and droplet precautions are recommended as standard practice for family and healthcare personnel caring for patients with MERS-CoV infection. However, the exact mode of nosocomial transmission, types of exposures that result in community-wide infections and the effectiveness of specific infection control measures in preventing transmission are not completely clear. Studies of healthcare workers and other patients exposed that have been admitted to the hospital with confirmed MERS-CoV cases can provide further insights on transmission and treatment.
At this juncture, no vaccination is available for MERS-CoV, nor has any anti-viral treatment been approved for the treatment of MERS. The most effective treatment currently is supportive care, often including hospitalization and use of ventilators, and intensive care for the sickest patients. For these reasons, effective population screening, early detection of cases and carriers, and quarantine for those posing risk of transmission should be considered the best methods for limiting the risk of a pandemic. It would also be advisable for U.S.-based hospitals to include a questionnaire and travel history for symptomatic patients upon arrival to the ER, especially during the high-risk exposure period following the Hajj pilgrimage.
Best practices for MERS detection and tracking
Results in minutes, not hours: PCR VS. RPA testing
Currently the WHO definition for laboratory confirmation of MERS-CoV infection specifies the use of polymerase chain reaction testing, which typically takes hours to days to complete and requires a clean laboratory environment with temperature controlled reagents. However, there is another option for detection and testing: the use of a rapid diagnostic test method called Reverse Transcription Recombinase Polymerase Amplification Assay. The RT-RPA assay could provide test results for MERS-CoV detection in 20 minutes or less. An RT-RPA test can also be performed in the field, with a simple mouth swab, providing immediately actionable results at a lower cost. Swab testing would be very effective to quickly identify and treat travelers to Saudi Arabia upon their arrival and also their departure during the Hajj pilgrimage. This type of field testing could facilitate the triage of people with the virus for appropriate management, including quarantine or treatment, and limit spreading the virus further by bringing it back to their home countries.
Hospital protocols: Identification, clinical surveillance and antimicrobial stewardship
The CDC advises that hospital personnel help protect themselves from respiratory illnesses like MERS by routinely taking everyday preventive actions, including washing your hands for 20 seconds, avoiding personal contact such as sharing cups or utensils, and disinfecting frequently touched surfaces such as toys and doorknobs.
In addition, clinical surveillance software should be considered to better manage patients that are currently being treated in the hospital. The National Healthcare Safety Network is a secure, internet-based surveillance system designed and maintained by the CDC to promote infection control best practices. Infectious disease surveillance can be performed manually, but it is costly and time-consuming. By adding clinical surveillance software into your current workflows, clinicians gain a dashboard view of all patients in order to access real-time information that can help reduce hospital-acquired infections, identify those at risk of new infections and take appropriate action in real-time, which could also prevent adverse events and readmissions. Clinical surveillance software can also improve care coordination and communications between infection control practitioners, pharmacists and laboratory personnel, and with an illness such as MERS-CoV, that real-time communication could be critical for identification, containment and timely treatment.
Antimicrobial stewardship best practices are also recommended for healthcare settings in order to manage infections like MERS. Antimicrobial stewardship solutions promote the appropriate use of antimicrobials (including antibiotics), to reduce microbial resistance, and decrease the spread of infections. They are often integrated in clinical surveillance software and normally include medication monitoring and management capabilities, automated antibiotic de-escalation, automated antibiogram and drug/bug mismatch alerts.
Infection tracking, population analytics and public health submissions
The NHSN has developed a number of protocols for infection tracking and remains the industry standard. Like clinical surveillance software, a robust infection tracking platform is also very important in closely monitoring the MERS-CoV virus. With numerous immunocompromised patients residing in a hospital, such as patients with severe pneumonia and those on ventilators, it is necessary to be able to identify and track patients with laboratory confirmed MERS-CoV. In addition to exposure in the hospital setting, there is also risk of a community outbreak if containment and treatment is not properly handled.
If managing a large number of patients with confirmed infections and also those with a high-risk of new infections, population analytics should also be considered in order to minimize new infections and monitor already infected patients. Population analytics not only analyzes individual patients, but can also provide population-level data that can identify system-wide infection issues and patterns, and can alert clinicians in real-time as to which of their patients are most in need of immediate care and identify patients that remain at risk.
Further, confirmed cases of a reportable disease, such as MERS-CoV, are mandated under meaningful use stage 2 to be submitted to the CDC, as well as the state's public health department. Electronic laboratory reporting is a meaningful use objective that has been promoted for wide public health adoption. However, these submissions can be difficult to conduct and submit manually. With an automated software solution, hospitals would be able to capture data from disparate database sources, organize that information and then complete an electronic data submission to fulfill the public health reporting requirements under the Medicare and Medicaid EHR Incentive Programs. This real-time reporting is critical for tracking and containing public health threats to the community.
Continuing research
Emerging medical research is helping us come to understand the nature of the MERS-CoV virus and potential treatments as a healthcare community, such as the recent New England Journal of Medicine and Science articles detailing cases of transmission of the virus. As the Science article mentions, "…scientists are confident that camels play a key role in the spread of the virus, but they don't know how it's transmitted between the animals or how it jumps the species barrier to humans."
There is still much to learn about the MERS-CoV virus, and as we get closer to the October 2014 Hajj pilgrimage, new infection protocols must be considered to identify, contain and properly treat infected and exposed individuals. The most comprehensive approach to MERS-CoV identification, containment and tracking is to incorporate surveillance software into current clinical workflows. Clinical surveillance systems arm hospitals and outpatient care settings with real-time, actionable information to help mitigate potential risks, treat patients who need it most and prevent the spread of MERS-CoV locally and globally.
Dr. Fauzia Khan currently serves as chief medical officer of Alere Analytics, where she provides direction and leadership to develop practical and scalable technologies that allow clinical decision support and analytic capabilities to be seamlessly incorporated into clinical workflows She has expertise and passion for algorithm design, knowledge acquisition and engineering as well as data mining and leveraging these capabilities to improve outcomes. Previously, Dr. Khan was the director of informatics at UMass Memorial Medical Center. She also has 10 years of experience practicing pathology. She is the author, editor and primary visionary of the "Guide to Diagnostic Medicine" (Lippincott Williams & Wilkins, 2002).