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      Critically ill healthcare workers with the middle east respiratory syndrome (MERS): A multicenter study

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          Abstract

          Background

          Middle East Respiratory Syndrome Coronavirus (MERS-CoV) leads to healthcare-associated transmission to patients and healthcare workers with potentially fatal outcomes.

          Aim

          We aimed to describe the clinical course and functional outcomes of critically ill healthcare workers (HCWs) with MERS.

          Methods

          Data on HCWs was extracted from a multi-center retrospective cohort study on 330 critically ill patients with MERS admitted between (9/2012–9/2015). Baseline demographics, interventions and outcomes were recorded and compared between survivors and non-survivors. Survivors were approached with questionnaires to elucidate their functional outcomes using Karnofsky Performance Status Scale.

          Findings

          Thirty-Two HCWs met the inclusion criteria. Comorbidities were recorded in 34% (11/32) HCW. Death resulted in 8/32 (25%) HCWs including all 5 HCWs with chronic renal impairment at baseline. Non-surviving HCW had lower PaO2/FiO2 ratios 63.5 (57, 116.2) vs 148 (84, 194.3), p = 0.043, and received more ECMO therapy compared to survivors, 9/32 (28%) vs 4/24 (16.7%) respectively (p = 0.02).Thirteen of the surviving (13/24) HCWs responded to the questionnaire. Two HCWs confirmed functional limitations. Median number of days from hospital discharge until the questionnaires were filled was 580 (95% CI 568, 723.5) days.

          Conclusion

          Approximately 10% of critically ill patients with MERS were HCWs. Hospital mortality rate was substantial (25%). Patients with chronic renal impairment represented a particularly high-risk group that should receive extra caution during suspected or confirmed MERS cases clinical care assignment and during outbreaks. Long-term repercussions of critical illness due to MERS on HCWs in particular, and patients in general, remain unknown and should be investigated in larger studies.

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          Most cited references19

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          Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia.

          A previously unknown coronavirus was isolated from the sputum of a 60-year-old man who presented with acute pneumonia and subsequent renal failure with a fatal outcome in Saudi Arabia. The virus (called HCoV-EMC) replicated readily in cell culture, producing cytopathic effects of rounding, detachment, and syncytium formation. The virus represents a novel betacoronavirus species. The closest known relatives are bat coronaviruses HKU4 and HKU5. Here, the clinical data, virus isolation, and molecular identification are presented. The clinical picture was remarkably similar to that of the severe acute respiratory syndrome (SARS) outbreak in 2003 and reminds us that animal coronaviruses can cause severe disease in humans.
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            Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study

            Summary Background Middle East respiratory syndrome (MERS) is a new human disease caused by a novel coronavirus (CoV). Clinical data on MERS-CoV infections are scarce. We report epidemiological, demographic, clinical, and laboratory characteristics of 47 cases of MERS-CoV infections, identify knowledge gaps, and define research priorities. Methods We abstracted and analysed epidemiological, demographic, clinical, and laboratory data from confirmed cases of sporadic, household, community, and health-care-associated MERS-CoV infections reported from Saudi Arabia between Sept 1, 2012, and June 15, 2013. Cases were confirmed as having MERS-CoV by real-time RT-PCR. Findings 47 individuals (46 adults, one child) with laboratory-confirmed MERS-CoV disease were identified; 36 (77%) were male (male:female ratio 3·3:1). 28 patients died, a 60% case-fatality rate. The case-fatality rate rose with increasing age. Only two of the 47 cases were previously healthy; most patients (45 [96%]) had underlying comorbid medical disorders, including diabetes (32 [68%]), hypertension (16 [34%]), chronic cardiac disease (13 [28%]), and chronic renal disease (23 [49%]). Common symptoms at presentation were fever (46 [98%]), fever with chills or rigors (41 [87%]), cough (39 [83%]), shortness of breath (34 [72%]), and myalgia (15 [32%]). Gastrointestinal symptoms were also frequent, including diarrhoea (12 [26%]), vomiting (ten [21%]), and abdominal pain (eight [17%]). All patients had abnormal findings on chest radiography, ranging from subtle to extensive unilateral and bilateral abnormalities. Laboratory analyses showed raised concentrations of lactate dehydrogenase (23 [49%]) and aspartate aminotransferase (seven [15%]) and thrombocytopenia (17 [36%]) and lymphopenia (16 [34%]). Interpretation Disease caused by MERS-CoV presents with a wide range of clinical manifestations and is associated with substantial mortality in admitted patients who have medical comorbidities. Major gaps in our knowledge of the epidemiology, community prevalence, and clinical spectrum of infection and disease need urgent definition. Funding None.
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              Hospital Outbreak of Middle East Respiratory Syndrome Coronavirus

              In September 2012, the World Health Organization reported the first cases of pneumonia caused by the novel Middle East respiratory syndrome coronavirus (MERS-CoV). We describe a cluster of health care-acquired MERS-CoV infections. Medical records were reviewed for clinical and demographic information and determination of potential contacts and exposures. Case patients and contacts were interviewed. The incubation period and serial interval (the time between the successive onset of symptoms in a chain of transmission) were estimated. Viral RNA was sequenced. Between April 1 and May 23, 2013, a total of 23 cases of MERS-CoV infection were reported in the eastern province of Saudi Arabia. Symptoms included fever in 20 patients (87%), cough in 20 (87%), shortness of breath in 11 (48%), and gastrointestinal symptoms in 8 (35%); 20 patients (87%) presented with abnormal chest radiographs. As of June 12, a total of 15 patients (65%) had died, 6 (26%) had recovered, and 2 (9%) remained hospitalized. The median incubation period was 5.2 days (95% confidence interval [CI], 1.9 to 14.7), and the serial interval was 7.6 days (95% CI, 2.5 to 23.1). A total of 21 of the 23 cases were acquired by person-to-person transmission in hemodialysis units, intensive care units, or in-patient units in three different health care facilities. Sequencing data from four isolates revealed a single monophyletic clade. Among 217 household contacts and more than 200 health care worker contacts whom we identified, MERS-CoV infection developed in 5 family members (3 with laboratory-confirmed cases) and in 2 health care workers (both with laboratory-confirmed cases). Person-to-person transmission of MERS-CoV can occur in health care settings and may be associated with considerable morbidity. Surveillance and infection-control measures are critical to a global public health response.

                Author and article information

                Contributors
                Role: MethodologyRole: ResourcesRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: Writing – review & editing
                Role: ResourcesRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: ValidationRole: Writing – review & editing
                Role: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                15 November 2018
                2018
                : 13
                : 11
                : e0206831
                Affiliations
                [1 ] Department of Medicine, Division of Infectious Diseases, University of Western Ontario, London, Canada, Department of Medicine, Division of Infectious Diseases, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
                [2 ] Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
                [3 ] Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
                [4 ] Department of Infection Prevention and Control, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
                [5 ] Department of Intensive Care, Alfaisal University, Dr Sulaiman Al-Habib Group Hospitals, Riyadh, Saudi Arabia
                [6 ] Department of Critical Care, King Fahad Hospital, Ohoud Hospital, Al-Madinah Al-Monawarah, Saudi Arabia
                [7 ] Department of Medicine, Alfaisal University, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
                [8 ] Department of Critical Care Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
                [9 ] Intensive Care Department, Al-Noor Specialist Hospital, Makkah, Saudi Arabia
                [10 ] Department of Critical Care Medicine, King Saud University, Riyadh, Saudi Arabia
                [11 ] Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
                [12 ] Intensive Care Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
                [13 ] Intensive Care Department, King Abdulaziz Hospital, Al Ahsa, Saudi Arabia
                [14 ] Department of Family and Community Medicine, King Abdulaziz University Hospital, Ministry of Health, Jeddah, Saudi Arabia
                [15 ] Intensive Care Department, King Fahd Hospital, Jeddah, Saudi Arabia
                [16 ] Department of intensive care, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
                [17 ] Infectious Diseases Data Observatory, Oxford University, Headiington, United Kingdom
                [18 ] Department of Critical Care Medicine and Department of Medicine, Sunnybrook Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
                [19 ] Department of Medicine, Division of Infectious Diseases and International Health University of Virginia School of Medicine, Charlottesville, Virginia, United States of America
                The University of Hong Kong, CHINA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0003-2414-4001
                http://orcid.org/0000-0002-8921-9628
                http://orcid.org/0000-0002-4168-1960
                http://orcid.org/0000-0001-5735-6241
                Article
                PONE-D-18-05294
                10.1371/journal.pone.0206831
                6237307
                30439974
                deaba4fc-279d-42a5-b5ee-e99626c67f51
                © 2018 Shalhoub et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 17 February 2018
                : 19 October 2018
                Page count
                Figures: 0, Tables: 4, Pages: 12
                Funding
                No specific funding for this work was received by any of the authors.
                Categories
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