Evaluation of visual triage for screening of Middle East respiratory syndrome coronavirus patients

Healthcare Workers' Assessment of a Visual Triage System (VTS)

Overcrowding and extended waiting times in the emergency department (ED) can pose a significant risk of COVID-19 transmission from patients to healthy individuals. In 2017, the Saudi Ministry of Health (MOH) introduced a visual triage system (VTS) with scoring to notify healthcare workers (HCWs) in EDs about the Middle East respiratory syndrome coronavirus (MERS-CoV) infection risk. During the COVID-19 pandemic, the MOH employed a VTS to classify patients according to their potential risk of COVID-19 infection upon their admission to the ED. Suspected patients were then directed along specific pathways to reduce their contact with healthy individuals. This study assessed HCWs' satisfaction with the VTS in the ED of two major government hospitals within the Riyadh region. Additionally, it assessed HCWs' perceptions of VTS effectiveness. This study used a cross-sectional, observational design and relied on surveys for data collection. A total of 127 participants completed the survey, of which 87 (68.5%) were based in the EDs of the two hospitals. Among the ED participants, 18.1% expressed satisfaction with the VTS, 46.4% were neutral, and 33.1% reported dissatisfaction. ED participants provided feedback on the system's effectiveness, with 24.1% finding it effective, 66.7% considering it somewhat effective, and 9.2% deeming it ineffective. Of the total (127) study participants (70.1%) reported that the HCWs required better training to effectively implement the VTS infection control plans for suspected cases. Fewer than half of the participants (35.4%) deemed the time spent by VTS personnel to identify COVID-19 cases to be reasonable, whereas 22% found it too short and 27.6% considered it too long. Of the total 127 participants, 63% reported that language differences between patients and HCWs constituted barriers to the effective application of the VTS. Our study findings indicated that most ED participants had a neutral outlook on their satisfaction with the VTS and a neutral perspective on the effectiveness of VTS, viewing it as only somewhat effective. Reported weaknesses and key obstacles to the successful implementation of the VTS included language barriers. and insufficient training for HCWs, and unclear VTS pathways. The reported strengths of the VTS included its effectiveness in reducing crowds and identification of COVID-19 patients.

Does a Low Score in the Respiratory Visual Triage Tool Predict a Negative COVID-19 Test in an Admitted Patient?

Background

Fast and accurate COVID-19 identification is important to population and epidemic monitoring in hospitals. Visual triage or respiratory triage should be efficient and utilized as visual clues to alert HCWs on the case definitions.

Objective

This study aims to evaluate the diagnostic value of the respiratory triage for COVID-19 infections and to evaluate the efficacy of the MOH triage tool in identifying low risk patients.

Methods

A single-center retrospective chart review that was conducted at King Fahd Hospital of the University (KFHU), Khober, KSA on all adult patients admitted to the hospital through the ED. The visual triage checklist comprises two main sections, with one focused on the risk of exposure and the other related to patient clinical signs and symptoms, each with a defined score where any score ≥ 4 will need to isolate and assessed by the physician while a score of less than 4 means that the patient can be admitted with other patients. The hospital swabbed all admitted patients regardless of their score. We compared their PCR result with their case definition score. The collected data was entered and analyzed using the Statistical Package for the Social Science (SPSS Inc. Chicago, IL, USA) version 23.

Results

The study included 7258 participants. 20% of participants aged between 21 to 30 years old, 52.2% of sample were females, and 78% were Saudi nationality. Visual triage score was less than 4 in n= 4745 participants (65.4%) and 4 or more in n= 2513 (34.6%). The test had sensitivity of 75% and specificity 21%.

Conclusion

Most studies shows that COVID 19 has an infectivity rate of 18 to 30%. Based on this low sensitivity result, using the screening tool alone puts patients and HCWs at risk of getting infected with COVID 19.

Comparing pregnancy outcomes between symptomatic and asymptomatic COVID-19 positive unvaccinated women- Multicenter study in Saudi Arabia

Introduction

COVID-19 infection in pregnancy ranges from asymptomatic infection to severe disease. However, the maternal and pregnancy outcomes are primarily favorable. Acute Respiratory Illness (ARI) score is a Visual Triage Checklist for Acute Respiratory symptoms created by the ministry of health of Saudi Arabia ¹² to screen the patient for acute respiratory infection with MERS-CoV. It has been used during the COVID-19 pandemic to identify suspected cases and place patients in isolation precautions if the score is≥ 4.

Method

This study is a cross-sectional study of all pregnant women who tested positive for COVID-19 in four medical centers located in four different cities in Saudi Arabia. The study period was from 1/3/2020 until 31/10/2020. Outcomes investigated were the prevalence of COVID infection in pregnant women at the time of delivery. Rate of asymptomatic disease, different maternal and pregnancy outcomes. Women were divided into symptomatic and asymptomatic groups according to the ARI score. The two groups were compared in maternal, perinatal, and neonatal outcomes. Furthermore, the cohort was divided according to maternal age into two groups: women of advanced maternal age ≥ 35 years and younger. The two groups were compared in maternal, perinatal, and neonatal outcomes

Results

During the study period, 9573 women gave birth at KAMCs, and 402 pregnant women were identified as COVID positive. Out of all COVID-positive women, only 394 women gave birth at KAMCs. The screening for COVID infection differed between the centers, but the testing was the same by the Nasopharyngeal polymerase chain reaction (PCR) swab. In Riyadh, screening was based on ARI scoring at the beginning of the pandemic. Then, it became universal. In Jeddah, the screening was based on ARI scoring. Any woman who scored four or more was labeled as suspected, and she was tested. Finally, in Madinah and Dammam, the screening was universal throughout the study.

The prevalence of COVID-19 infection among women who gave birth at KAMCs was 4.2% (402/9573). (CI 3.8–4.6%). At the time of diagnosis, most women (62%) were asymptomatic. The most common symptoms were cough and shortness of breath. Twenty-two women (5.5%) had Pneumonia, and five women (1.3%) needed admission to Intensive care units (ICU). One woman died due to respiratory failure.

When pregnancy outcomes were compared between symptomatic and asymptomatic women, pregnancy in symptomatic women was more likely to be complicated by Abortion (6 versus 2% p-value 0.00), fetal death (3 versus 1.3%), and cesarean delivery (30.8 versus 22.4%, p-value 0.001). COVID-positive pregnant women of advanced maternal age (AMA) were more likely to be symptomatic, have Abortion (5 versus 1%, p-value 0.01), and have Preterm delivery (17 versus 11% p-value 0.01) than younger women. In addition, neonatal death was more common in AMA COVID-positive women than younger (4 versus 0%), regardless of COVID-related symptoms.

Conclusion

Most of the COVID-infected pregnant women are asymptomatic. Therefore, the ARI scoring system does not help to triage patients. Symptomatic women, especially those older than 35, tend to have a higher maternal and pregnancy complication rate.

Middle East Respiratory Syndrome Coronavirus

The past two decades have witnessed the emergence of three zoonotic coronaviruses which have jumped species to cause lethal disease in humans: severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1), Middle East respiratory syndrome coronavirus (MERS-CoV), and SARS-CoV-2. MERS-CoV emerged in Saudi Arabia in 2012 and the origins of MERS-CoV are not fully understood. Genomic analysis indicates it originated in bats and transmitted to camels. Human-to-human transmission occurs in varying frequency, being highest in healthcare environment and to a lesser degree in the community and among family members. Several nosocomial outbreaks of human-to-human transmission have occurred, the largest in Riyadh and Jeddah in 2014 and South Korea in 2015. MERS-CoV remains a high-threat pathogen identified by World Health Organization as a priority pathogen because it causes severe disease that has a high mortality rate, epidemic potential, and no medical countermeasures. MERS-CoV has been identified in dromedaries in several countries in the Middle East, Africa, and South Asia. MERS-CoV-2 causes a wide range of clinical presentations, although the respiratory system is predominantly affected. There are no specific antiviral treatments, although recent trials indicate that combination antivirals may be useful in severely ill patients. Diagnosing MERS-CoV early and implementation infection control measures are critical to preventing hospital-associated outbreaks. Preventing MERS relies on avoiding unpasteurized or uncooked animal products, practicing safe hygiene habits in health care settings and around dromedaries, community education and awareness training for health workers, as well as implementing effective control measures. Effective vaccines for MERS-COV are urgently needed but still under development.

MERS-CoV Confirmation among 6,873 suspected persons and relevant Epidemiologic and Clinical Features, Saudi Arabia - 2014 to 2019

BACKGROUND

Of the three lethal coronaviruses, in addition to the ongoing pandemic-causing SARS-CoV 2, Middle East Respiratory Syndrome Coronavirus (MERS-CoV) remains in circulation. Information on MERS-CoV has relied on small sample of patients. We updated the epidemiology, laboratory and clinical characteristics, and survival patterns of MERS-CoV retrospectively with the largest sample of followed patients.

METHODS

We conducted a retrospective review of line-listed records of non-random, continuously admitted patients who were suspected (6,873) or confirmed with MERS-CoV (501) admitted to one of the four MERS-CoV referral hospitals in Saudi Arabia, 2014-2019.

FINDINGS

Of the 6,873 MERS-CoV suspected persons, the majority were male (56%) and Saudi nationals (83%) and 95% had no known history that increased their risk of exposure to MERS-CoV patients or vectors (95%). More confirmed cases reported history that increased their risk of MERS-CoV infection (41%). Among the suspected, MERS-CoV confirmation (7.4% overall) was independently associated with being male, known transmission link to MERS-CoV patients or vectors, fever, symptoms for 7 days, admission through intensive care unit, and diabetes. Among persons with confirmed MERS-CoV, single symptoms were reported by 20%, 3-symptom combinations (fever, cough and dyspnea) reported by 21% and 2-symptom combinations (fever, cough) reported by 16%. Of the two-thirds (62%) of MERS-CoV confirmed patients who presented with co-morbidity, 32% had 2-"comorbidities (diabetes, hypertension). More than half of the MERS-CoV patents showed abnormal chest X-ray, elevated aspartate aminotransferase, and creatinine kinase. About a quarter of MERS-CoV patients had positive cultures on blood, urine, or respiratory secretions. During an average hospital stay of 18 days (range 11 to 30), 64% developed complications involving liver, lungs, or kidneys. Ventilation requirement (29% of MERS-CoV cases) was independently associated with abnormal chest X-ray, viremia (Ct value <30), elevated creatinine, and prothrombin time. Death (21% overall) was independently associated with older age, dyspnea and abnormal chest X-ray on admission, and low hemoglobulin levels.

INTERPRETATIONS

With two-thirds of the symptomatic persons developing multiorgan complications MERS-CoV remains the coronavirus with the highest severity (29%) and case fatality rate (21%) among the three lethal coronaviruses. Metabolic abnormalities appear to be an independent risk factor for sustained MERS-CoV transmission. The poorly understood transmission dynamics and non-specific clinical and laboratory features call for high index of suspicion among respiratory disease experts to help early detection of outbreaks. We reiterate the need for case control studies on transmission.

FUNDING

No special funding to declare.

Improving turnaround time of molecular diagnosis of Middle East respiratory syndrome coronavirus in a hospital in Saudi Arabia

Background

There have been 2562 laboratory-confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) in 27 countries, with a case fatality rate of 34.5%. Data on the turnaround time (TAT) are lacking. We report TAT for MERS-CoV samples over time.

Methods

This is a monocentric study and the TAT for the reporting of 2664 MERS-CoV polymerase chain reaction (PCR) results were calculated in hours from the time of the receipt of respiratory samples to the reporting of the results.

Results

The mean TAT±standard deviation was significantly lower in 2018 compared with previous years (19.25±13.8). The percentage of samples processed within 24 h increased from 42.3% to 73.8% in 2015 and 2018, respectively (p<0.0001). The mean TAT was 19.2 h in 2018 and was significantly lower than previous years.

Conclusions

The TAT for the MERS-CoV results decreased during the study period. Timely reporting of MERS-CoV PCR results may aid in further enhancing infection control measures.

Prevalence of COVID-19-related anxiety among healthcare workers: A cross-sectional study

Introduction:

COVID-19 was labeled as a pandemic in March 2020. Healthcare workers (HCW) are confronting great mental stressors in coping with the crisis. In Saudi Arabia, research on the psychological effect of COVID-19 on HCW is lacking.

Aim:

To evaluate COVID-19 psychological impact on HCW and determine anxiety predictors to identify high-risk individuals.

Materials and Methods:

A descriptive cross-sectional study was conducted on HCW in First Health Cluster Institutes in Eastern Province. An English self-administered questionnaire was adopted from similar research done in China. The original questionnaires were modified to meet the objectives of our study and suit Saudi sociodemographic differences. Generalized anxiety disorder-7 scale was incorporated to be the main tool for assessing the psychological impact.

Results:

One-third of HCW were classified as having anxiety disorder. In univariate analyses, the age group in years (P = 0.026), gender (P = 0.001), nationality (P = 0.033), and living with family (P = 0.007) significantly influenced anxiety disorder. However, in the multivariate regression model, gender (P = 0.004), living with family (P = 0.021), family history of COVID-19 (P = 0.022), and been suspected or confirmed with COVID-19 infection (P = 0.018) remained statistically significant when compared to anxiety disorder.

Conclusion:

During early COVID-19 pandemic, anxiety disorder among HCW was noticeable. Being a female, living with family members, and having a family history of COVID-19 increased the risk for anxiety disorder.

Middle East Respiratory Syndrome Coronavirus and Severe Acute Respiratory Syndrome Coronavirus

Emerging infectious diseases continue to be of a significant importance worldwide with the potential to cause major outbreaks and global pandemics. In 2002, the world had witnessed the appearance of the severe acute respiratory syndrome coronavirus in China which disappeared abruptly within 6 months. About a decade later, a new and emerging novel coronavirus named the Middle East respiratory syndrome coronavirus (MERS-CoV) was described in a patient from Saudi Arabia. These two coronaviruses shared multiple similarities in the epidemiology, clinical presentations, and posed challenges in its prevention and management. Seven years since its discovery, MERS-CoV continues to be a lethal zoonotic pathogen capable of causing severe pneumonia with high case fatality rates and the ability to cause large health care-associated outbreaks.

Middle East respiratory syndrome coronavirus in the last two years: Health care workers still at risk

BACKGROUND

An important emerging respiratory virus is the Middle East respiratory syndrome coronavirus (MERS-CoV). MERS-CoV had been associated with a high case fatality rate especially among severe cases.

METHODS

This is a retrospective analysis of reported MERS-CoV cases between December 2016 and January 2019, as retrieved from the World Health Organization. The aim of this study is to examine the epidemiology of reported cases and quantify the percentage of health care workers (HCWs) among reported cases.

RESULTS

There were 403 reported cases with a majority being men (n = 300; 74.4%). These cases were reported from Lebanon, Malaysia, Oman, Qatar, Saudi Arabia, and United Arab Emirates. HCWs represented 26% and comorbidities were reported among 71% of non-HCWs and 1.9% among HCWs (P < .0001). Camel exposure and camel milk ingestion were reported in 64% each, and the majority (97.8%) of those with camel exposures had camel milk ingestion. There were 58% primary cases and 42% were secondary cases. The case fatality rate was 16% among HCWs compared with 34% among other patients (P = .001). The mean age ± SD was 47.65 ± 16.28 for HCWs versus 54.23 ± 17.34 for non-HCWs (P = .001).

CONCLUSIONS

MERS-CoV infection continues to have a high case fatality rate and a large proportion of patients were HCWs. Further understanding of the disease transmission and prevention mainly in health care settings are needed.

Call to action for improved case definition and contact tracing for MERS-CoV

Progress has been made in KSA in reducing the number and size of healthcare facilities outbreaks of MERS-CoV by the application of wide scope case definition leading to excessive MERS-CoV testing. Critical case definition review and application of point of care testing with revision of HCWs furlough are urgently needed.