Al-Tawfiq, Jaffar A.

Alfaraj, Sarah H.

Altuwaijri, Talal A.

Memish, Ziad A.

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MANUSCRIPT ACCEPTEDACCEPTED MANUSCRIPTA cohort-study of patients suspected for MERS-CoV in a referral hospital in Saudi Arabia Jaffar A. Al-Tawfiq a,b, Sarah H. Alfarajc, Talal A. Altuwaijri d,  Ziad A. Memish e, f,g a   Johns Hopkins Aramco Healthcare, Dhahran, Kingdom of Saudi Arabia b   Indiana University School of Medicine, Indianapolis, IN, USA c   Corona Center, Infectious Diseases Division, Department of Pediatric , Prince Mohamed Bin Abdulaziz Hospital,  Ministry of Health, Riyadh, Saudi Arabia d   Department of Surgery, Prince Mohamed Bin Abdulaziz Hospital, Ministry of Health, Riyadh, Saudi Arabia e College of Medicine, Alfaisal University, Riyadh, Saudi Arabia f. Infectious Diseases Division, Department of Medicine, Prince Mohamed Bin AbdulazizHospital, Ministry of Health,  Riyadh, Saudi Arabia g Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, USA  All authors have no conflict of interest to report _________________________________________________________________________________ This is the author's manuscript of the article published in final edited form as: Al-Tawfiq, J. A., Alfaraj, S. H., Altuwaijri, T. A., & Memish, Z. A. (2017). A cohort-study of patients suspected for MERS-CoV in a referral hospital in Saudi Arabia. Journal of Infection. https://doi.org/10.1016/j.jinf.2017.06.002MANUSCRIPT ACCEPTEDACCEPTED MANUSCRIPT2 Ko and colleagues recently published predictive factors for pneumonia in patients infected with Middle East respiratory syndrome-coronavirus (MERS-CoV) [1].   The differentiation between MERS-CoV and non-MERS-CoV was evaluated in few studies with no significant findings [2–4].  In this study, we review a large cohort of patients who were admitted to one (Prince Mohammed bin Abdulaziz Hospital) of the 4 MERS-CoV reference centers under the umbrella of the Ministry of Health (MoH) to rule out MERS-CoV with the aim to compare MERS-CoV positive patients to non-MERS-COV patients.  Prince Mohammed bin Abdulaziz Hospital (PMAH) is referral center for all MERS-CoV patients diagnosed in the central region based in Riyadh, Saudi Arabia.  The study included all patients from April 1st 2014 to December 2016. MERS-CoV testing was done using nasopharyngeal swabs and tested using real time reverse transcriptase PCR as described previously [5].  In this cohort, we compared MERS-CoV patients to non-MERS-CoV patients.  The comparison used percentage for categorical data and mean + standard deviation (SD) for continuous data.   A p value of < 0.05 was considered significant. During the study period, there were a total of 2151 patients who were admitted for evaluation for MERS-CoV.  Of those patients, 1856 (86.3%) were non-MERS-CoV, and 295 (13.7%) were MERS-CoV patients.  Male gender was 61% among MERS-CoV patients and 53.7% among non-MERS-CoV patients (P = 0.019).  There was no difference in the mean age of MERS-CoV patients (47.3 + 17.8 years) compared with 554.6 + 22.1 years in the non-MERS-CoV patients. Overall, the age group 21-40 and 41-60 years were more common among MERS-CoV patients (36.9% vs. 24.4% and 32.9% vs. 22.5%, respectively).  Cough and shortness of breath were less common in the MERS-CoV than non-MERS-CoV patients (41.4% vs. 50.3% and 54.2% vs. 66%).  Healthcare workers represented 14.9% and 2.6% (P = 0.0001) in the MERS-CoV than non-MERS-CoV patients, respectively.  The mean WBC count was not significantly lower in MANUSCRIPT ACCEPTEDACCEPTED MANUSCRIPT3  MERS-CoV vs. non-MERS-CoV patients (mean 7.47 vs 11.5, P =1).  The case fatality rate was significantly lower in the non-MERS-CoV (9.2%) compared with MERS-CoV (20%) (P = 0.0001).   This is the largest cohort study of MERS-CoV and non-MERS-CoV patients.  Previously, there were three case-control studies of MERS-CoV vs. non-MERS-CoV patients.  The first study included 17 MERS-CoV patients and 82 non-MERS-CoV patients with a high mortality rate of 76% and 15% among MERS-CoV and non-MERS-CoV patients respectively.  The second study included 80 MERS-CoV patients and was matched to 159 non-MERS-CoV patients with a recorded mortality rate of 10%vs. 4.4%.  A third study from Saudi Arabia included 48 patients with MERS-CoV infection and 111 MERS-CoV negative patients.  The study included patients from October 2012 to April 2014 and the case fatality rates were 35% and 22% respectively.  The current study included a larger number of patients spanning a longer duration and the case fatality rate was only 20%.   This case fatality rate was different in varioust hospitals and ranged from 28.6% to 63.6% [6].  The current study had a case fatality rate that is close to the South Korea rate and lower than the overall all rate (38.7%) and the Kingdom-wide rate of 36.5% [7].  The variability of the case-fatality rates may be related to host factors, co-morbidities, care provided and yet unidentified factors [6]. Most of the cases of MERS occurred in the healthcare settings [2,8].  The proportion of healthcare workers (HCWs) in these outbreaks is variable.  In a study of 70 cases, at least 50% of the cases were acquired in the hospital setting [9].  In the 2014 Jeddah outbreak, there were 128 laboratory-confirmed cases in 14 hospitals between February 17 and April 26, 2014 [10].  Of these cases, 33% were primary cases and >60% (including 39 HCWs) were acquired within healthcare facilities.  In the current study, HCWs represented 14.9% and 2.6% (P = 0.0001) in MANUSCRIPT ACCEPTEDACCEPTED MANUSCRIPT4  the MERS-CoV and non-MERS-CoV patients, respectively.  However, the hospital is a referral hospital for all MERS cases in the Riyadh region and thus the finding does not represent the transmission within the same hospital.  In conclusion, the case fatality rate was higher in the MERS than non-MERS and healthcare workers were more common among MERS patients.  References: [1] Ko J-H, Park GE, Lee JY, Lee JY, Cho SY, Ha YE, et al. Predictive factors for pneumonia development and progression to respiratory failure in MERS-CoV infected patients. J Infect 2016;73:468–75. doi:10.1016/j.jinf.2016.08.005. [2] Al-Tawfiq JA, Hinedi K, Ghandour J, Khairalla H, Musleh S, Ujayli A, et al. Middle East Respiratory Syndrome-Coronavirus (MERS-CoV): a case-controlstudy of hospitalized patients. Clin Infect Dis 2014;59:160–5. doi:10.1093/cid/ciu226. [3] Mohd HA, Memish ZA, Alfaraj SH, McClish D, Altuwaijri T, Alanazi MS, et al. Predictors of MERS-CoV infection: A large case control study of patients presenting with ILI at a MERS-CoV referral hospital in Saudi Arabia. Travel Med Infect Dis 2016;14:464–70. doi:10.1016/j.tmaid.2016.09.008. [4] Garbati MA, Fagbo SF, Fang VJ, Skakni L, Joseph M, Wani TA, et al. A Comparative Study of Clinical Presentation and Risk Factors for Adverse Outcome in Patients Hospitalised with Acute Respiratory Disease Due to MERS Coronavirus or Other Causes. PLoS One 2016;11:e0165978. doi:10.1371/journal.pone.0165978. [5] Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah FA, Al-Hajjar S, Al-Barrak A, et al. MANUSCRIPT ACCEPTEDACCEPTED MANUSCRIPT5  Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: A descriptive study. Lancet Infect Dis 2013;13:752–61. doi:10.1016/S1473-3099(13)70204-4. [6] Nam H-S, Park JW, Ki M, Yeon M-Y, Kim J, Kim SW. High fatality rates and associated factors in two hospital outbreaks of MERS in Daejeon, the Republic of Korea. Int J Infect Dis 2017. doi:10.1016/j.ijid.2017.02.008. [7] Kim KH, Tandi TE, Choi JW, Moon JM, Kim MS. Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in South Korea, 2015: epidemiology, characteristics and public health implications. J Hosp Infect 2017;95:207–13. doi:10.1016/j.jhin.2016.10.008. [8] Al Hosani FI, Pringle K, Al Mulla M, Kim L, Pham H, Alami NN, et al. Response to Emergence of Middle East Respiratory Syndrome Coronavirus, Abu Dhabi, United Arab Emirates, 2013–2014. Emerg Infect Dis 2016;22:1162–8. doi:10.3201/eid2207.160040. [9] Saad M, Omrani AS, Baig K, Bahloul A, Elzein F, Matin MA, et al. Clinical aspects and outcomes of 70 patients with Middle East respiratory syndrome coronavirus infection: a single-center experience in Saudi Arabia. Int J Infect Dis 2014;29:301–6. doi:10.1016/j.ijid.2014.09.003. [10] Drosten C, Muth D, Corman VM, Hussain R, Al Masri M, HajOmar W, et al. An observational, laboratory-based study of outbreaks of middle East respiratory syndrome coronavirus in Jeddah and Riyadh, kingdom of Saudi Arabia, 2014. Clin Infect Dis 2015;60:369–77. doi:10.1093/cid/ciu812. MANUSCRIPT ACCEPTEDACCEPTED MANUSCRIPT6  Table 1: Comparison of characteristics of non-MERS-CoV and MERS-CoV patients   Non MERS-CoV (Number) Non-MERS-CoV (%) MERS-CoV (Number) MERS-CoV  (%) P value Number 1856  295   Male 997 53.7 180 61.0 0.0199 0-20 116 6.3 8 2.7 0.014 21-40 453 24.4 109 36.9 0.0001 41-60 417 22.5 97 32.9 0.0002 61-80 683 36.8 75 25.4 0.0001 81-100 187 10.1 6 2.0 0.0001 Abnormal CXR 1170 63.0 182 61.7 0.6505 Fever 1718 92.6 282 95.6 0.065 Symptoms 1814 97.7 252 85.4 0.0001 GI symptoms 228 12.3 32 10.8 0.5638 SOB 934 50.3 122 41.4 0.0047 Cough 1225 66.0 160 54.2 0.0001 Healthcare workers 48 2.6 44 14.9 0.0001 Mechanical ventilation 168 9.1 69 23.4 0.0001 Death 171 9.2 59 20.0 0.0001  MANUSCRIPT ACCEPTEDACCEPTED MANUSCRIPT7   Table 2: Comparison of the means between non-MERS-CoV and MERS-CoV patients    Non-MERS-CoV SD MERS-CoV SD P value  Mean age 54.6 22.1 47.3 17.8 1.0 WBC 11.5 6.53 7.47 4.31 1.0 Hgb 125.8 27.1 129.1 25.1 0.037 Platelet 280 131.4 227 107.7 < 0.0001 PMN Absolute 14.72 128.0 9.46 65.0 0.29   

A cohort-study of patients suspected for MERS-CoV in a referral hospital in Saudi Arabia

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A cohort-study of patients suspected for MERS-CoV in a referral hospital in Saudi Arabia

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