Infectious Diseases MERS- CoV Plans for Hajj 1436 · Disclaimer for use of this document This document: Focuses on protocols to follow during the 1436 Hajj season Focuses on Hajj

Infectious Diseases MERS-

CoV Plans for Hajj 1436

Last updated: 19/9/2015

MERS-CoV Diversion Plans for Hajj

Purpose of this document

▪ Document clinical operations protocols that must

be followed for MERS–CoV cases diversions to

appropriate facilities during the 1436 Hajj season

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Disclaimer for use of this document

This document:

▪ Focuses on protocols to follow during the 1436 Hajj season

▪ Focuses on Hajj related locations (Makkah, Madinah, Holy Sites, and

Jeddah) and does NOT cover protocols to follow in other regions in KSA

▪ Is NOT intended as a comprehensive MERS-CoV response guideline

▪ Should be supplemented with other important guidelines such as Haj plan

1436 and infection prevention and control and isolation guidelines which are

found on the MOH website:

– MERS-CoV guideline :

http://www.moh.gov.sa/en/CCC/StaffRegulations/Corona/

Documents/IPC%20Guidelines%20for%20MERS-

coV%20Infection.pdf

– Is subject to change as guidelines are updated

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http://www.moh.gov.sa/en/CCC/StaffRegulations/Corona/Documents/IPC Guidelines for MERS-coV Infection.pdf

▪ Dr Abdullah Assiri, the Assistant Deputy Minister for preventive Health

▪ Dr. Tariq Al-Arnous, The General Director of General Directorate of Medical Emergency

▪ Dr. Abdulhafiz Turkustani, General Director Assistant for Public Health, Makkah Region

▪ Dr Ali Albarrak, Saudi Centers for Disease Control

▪ Dr Hail Al-Abdely , General Director of the General Directorate of Infection Prevention and Control

▪ Dr. Raafat Al-Hakeem, The Director-General of Communicable Diseases Control

▪ Nasser Abutaleb, 937 Callcenter Director

This document was modified and updated by

Acknowledgments

For any comments, clarifications, or recommendations pertaining to this

document please email Dr. Wail Tashkandi at

[email protected]

For any comments, clarifications, or recommendations pertaining to this document please email Mr.Nasserabutaleb at [email protected]

Contents

▪ Guiding principles

▪ Case definitions

▪ MERS-CoV dedicated teams

▪ MERS-CoV diversion plans

▪ Transfer protocols

▪ Home isolation protocols

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General guiding principles to follow in handling MERS-CoV cases (1 of 2)

1 Case definitions available on MoH websites: MERS-CoV

http://www.moh.gov.sa/en/CCC/StaffRegulations/Corona/Documents/IPC%20Guidelines%20for%20MERS-coV%20Infection.pdf

2 Transfer protocols available in this document

General

▪ All hospital staff should be aware of latest MERS-CoV case

definitions1

▪ At all times, handle suspect patients with appropriate protection

equipment (i.e. PPEs applied on patients and by health

professionals) and follow all recommended IPC guidelines2

▪ When transferring patients to other locations, transfer protocols2 should be

followed

▪ For other infectious diseases not covered in this guideline, please follow

standard MoH guidelines

The following principles were followed to create the referral pathways. They should be

followed in case of doubt or when handling cases not specifically addressed in this guide:

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General guiding principles to follow in handling MERS-CoV cases (2 of 2)

1 Transfer protocols available in this document

Suspected

cases

▪ MERS-CoV: When possible (i.e. isolation room and adequate personal available),

preference is to admitting suspect MERS-CoV patients in same facility that

received patient rather than transferring patient to other ERs or MERS-CoV

Designated Hospitals (MDH) or (CoE)

▪ MERS-CoV: Confirmed MERS-CoV patients should be transferred to MERS-CoV

Designated Hospitals (MDH) or Center of Excellence (CoE) following appropriate

transfer protocols1

Confirmed

cases

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Suspect case (patients who should be tested for MERS-CoV)

Adults (> 14 years)

I. Acute respiratory illness with clinical and/or radiological,

evidence of pulmonary parenchymal disease (pneumonia or

Acute Respiratory Distress Syndrome .

OR

II. A hospitalized patient with healthcare associated pneumonia

based on clinical and radiological evidence.

OR

III. Upper or lower respiratory illness within 2 weeks after

exposure to a confirmed or probable case of MERS-CoV

infection.

OR

IV. Unexplained acute febrile (≥38°C) illness, AND body aches,

headache, diarrhea, or nausea/vomiting, with or without

respiratory symptoms, AND leucopenia (WBC)

Pediatrics (≤ 14 years)

I. Meets the above case definitions and has at least one of the

following

a. History of exposure to a confirmed or suspected

MERS CoV in the 14 days prior to onset of symptoms

b. History of contact with camels or camel products in

the 14 days prior to onset of symptoms

II. Unexplained severe pneumonia

▪ A probable case is a

patient in category I or

II above (Adults and

pediatrics) with

inconclusive laboratory

results for MERS-CoV

and other possible

pathogens who is a

close contact of a

laboratory-confirmed

MERS-CoV case or who

works in a hospital

where MERS-CoV cases

are cared for or had

recent contact with

camels or camel’s

products. Confirmed

case

▪ confirmed case is a

person with laboratory

confirmation of

MERS-CoV infection

MERS-CoV case definition

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Dedicated teams, reachable through the 937 hotline, will be in place to

assist in managing MERS-CoV

MERS-CoV

▪ MERS-CoV Team: Infectious Diseases consultant on call that can help in

diagnosing cases over the phone and advising on appropriate course of action

to take

▪ ECMO team: Emergency team that responds when there is an ECMO need to

insert ECMO and transfer the patient

Teams, reachable through the 937 hotline, who can help in diagnosing, handling, or

transferring cases

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ECMO Leads in Center of Excellence will be in place to assist in managing

MERS-CoV cases, through the 937 hotline

▪ Age < 60 years old with potential reversible lung pathology.

▪ PF ratio (PaO2:FiO2) < 80 mmHg with FiO2 at 100%.

▪ Respiratory acidosis (PH < 7.2).

▪ PEEP > 15 cm H2O with Pplat > 35 cm H2O.

▪ Murray score 3 - 4 .

▪ No absolute contradiction for ECMO

Indication for V-V ECMO

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▪ MERS-CoV teams




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Identification of suspected MERS-CoV cases at Hospitals and PHCs at

Makkah, Holy Sites, Madinah, and Jeddah

History of contact with a known MERS-CoV case

in the last month OR

History of direct or indirect contact with camels in

the last month

YES

Put regular mask on

patient and companions.

Separate physically from

other patients.

Inform IPC and PH

CXR, CBC and swab for

MERS-CoV and Influenza

NO

Treat symptomatically

Educate on respiratory

and hand hygiene

Supply with medical

mask,Discharge if

medically fit

NO

YES

In PHC, if a patient is suspected, transfer

patient to nearest hospital. If patient is

clinically stable and it’s difficult to transfer

due to logistical challenges, apply mask and

direct him/her to the nearest hospital

Acute respiratory symptoms (cough, SOB,

runny nose, sore throat)

Clinical signs

of pneumonia?

Diversion plan for a suspect MERS-CoV (ICU and non-ICU) patient in

Makkah, Madinah or Jeddah Hospitals

Suspected1

patient

Immediately give

patient a mask

Admit to

isolation

room

Is isolation

room

available?

Yes No

Test MERS-CoV

and influenza

MERS-

CoV

Team

decision

Initiate

transfer to MDH or CoE2,3 or

Notify

hospital

IPC team

Call 937

(MERS-

CoV Team) if

support or

consultation

needed

Transfer to

MDH

Admit: Hospital IPC team to ensure

appropriate measures are taken (beds

are separated by 1-1.5 meters

1 Refer to MERS-CoV case definition as per MoH’s MERS-CoV online guideline : http://www.moh.gov.sa/en/CCC/StaffRegulations/Corona/Documents/IPC%20Guidelines%20for%20MERS-coV%20Infection.pdf

2 Follow transfer from hospital protocol presented in this guide

3 List of MDHs presented in this guide

4 937 has latest list of MDH hospitals

Keep in hospital

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Diversion plan for a confirmed MERS-CoV (ICU and non-ICU) patient in

Makkah, Madinah, Holy Sites, or Jeddah Hospitals

1 Refer to MERS-CoV case definition as per MoH’s MERS-CoV online guideline : http://www.moh.gov.sa/en/CCC/StaffRegulations/Corona/Documents/IPC%20Guidelines%20for%20MERS-coV%20Infection.pdf

2 Follow protocol for confirming +ve MERS-CoV case

3 Follow transfer from hospital protocol

4 937 has latest list of MDH hospitals

Confirmed MERS-

CoV ICU patient1,2

Initiate transfer to

MDH through

MERS-CoV team

(937)3,4

Notify hospital IPC

team

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Special note regarding allowing suspect or confirmed MERS-CoV cases to

participate in the Hajj caravan on the day of Arafa

On the day of Arafa, confirmed/suspect MERS-CoV patients can join

the Hajj Caravan bus (if they are fit to do so). The following

precautions are to be followed:

Patients are to be seated 1 to 1.5 meters apart

Patients are to wear surgical masks, keep on changing the masks

when they get wet

Patients are not allowed to leave the bus

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Transfer protocol of a MERS-CoV case from a Hospital to an MDH

Patient needs

ECMO

Is patient

transferable?

Initiate ground transport

ICU patient

Confirmed MERS-CoV

patient in Laboratory

Laboratory

Communicates with

Public Health and

Hospital

Hospital (MD) calls

MERS-CoV team (937)

Continue ICU

management

ECMO team reaches

patient in same hospital

communication with Dr.

Tariq Al-Arnous or his

designee

937 Will connect the MD

with receiving MDH; and

connct with ID /ICU if per

consultation regarding

management … etc

YesYes

No

No

Yes

Is ground

transfer faster

than air?

Yes

No

Initiate air transport

No

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Air transport execution protocol for MERS-CoV cases

Air transport

request

Call Dr. Tariq Al-

Arnous or his

designee1

Saudi Red

Crescent team

Confirmed

MERS-CoV

patient

Air transport

Air transport

YesNo

1 Through the radio network

or phone or his disgnee

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Transfer protocol for ECMO

Hospital calls hotline (937)

and connects to ID

consultant on call

Situation Room

will follow up till

the transfer has

been completed

On call consultant

1. Assesses patient eligibility

For ECMO with

the Intensivist in

the respective

CoE

2. Understands patient

details and transfer

locations

3. Receive contact

information of intenvsist

physician at the receiving

CoE and treating

physician

Dispatch ECMO team

▪ Level 3 ambulance to

transport surgeon,

perfusionist and ECMO

machine to referring

hospital for insertion,

stabilization of patient

and transport back to

MERS-CoV Designated

Hospital

CallAlpha Star to initiate

air ambulance with ECMO

team

No

Yes

Is helipad

available?

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▪ MERS-CoV teams




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Home isolation in Makkah protocol

If rooms not available or not meeting required

standard, isolation at (Almutahasneen Sections)

at Noor hospital

Follow diversion plans

Provide room in mission

housing according to

isolation standards.

(There are rooms that

have been reserved for

isolation)

Case needs

admission

Case does not

need admission – asymptomatic

or suspected contact

Local

residentsPilgrims

Isolate citizens

in their home

after assurance

of suitability by

the preventive

team

MERS-CoV Patient

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Home isolation in Madinah

Follow diversion plans

Case needs

admission

MERS-CoV Patient

Cases that don’t need

admission shall be quarantined

in their hotel if suitable

If hotel is not suitable, cases

shall be quarantined in Ohoud

Hospital

If ohoud Hospital is full, cases

shall be quarantined in Miqat

Hospital

If is full, cases shall be

quarantined In Rehabilitation

Hospital

If Al Miqat Hospital is full, cases

shall be quarantined at Pilgrim

City hospital

If Pligrim city is full, cases shall

be quarantined at primary

healthcare centers

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Specific Madinah & Jeddah hospitals have been designated to handle

confirmed MERS-CoV cases

Jeddah▪ KAMC-Jeddah

Madinah ▪ Ohoud

Surge plansMERS-CoV

Designated Hospital

a) If surge reached at KAMC-Jeddah, transfer Non-

MERS patients to MOH governmental hospital and

private hospitals, if needed.

b) If KAMC-Jeddah is full, transfer to East Jeddah.

c) If surge reached at East Jeddah, transfer to King Faisal

hospital in Taif. If ECMO is needed transfer to PMAH-

Riyadh/ Dammam Medical Complex through 937

a) If surge reached at Ohoud, transfer to King Faisal

hospital Taif.

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a) if surge reach KAMC, transfer to East Jeddah

b) If surge reached East Jeddah, transfer to King Faisal

hospital in taif. If ECMO is needed transfer to PMAH-

Riyadh/ Dammam Medical Complex through 937

▪ Any Confirmed

MERS-CoV

case among

pilgrims or citizens

or

residents: (KAMC).

Makkah

&

Holy

Sites

(pilgrims

or

resident)

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Suspected MERS-

CoV1

Using approved swabs2

Trained nurse or physician

collect samples3 in a

designated area4

Report to public health

officer and infection

control at your hospital

Send samples to your

hospital lab

Get a notification number

from PH officer and add

this number to lab request

plus HESN Code.

Hospital lab call

(5504518 or 5572593)

landline for pickup

Sending a MERS-CoV specimen from Mashaer hospitals to the lab

(valid from 8 to 15 Thul hejjah 1436)

1- See definition in

page 8

2- Swabs with transport

media are available at

hospitals labs,

additional swabs will

be provided by public

health officer at your

hospital

3- Preferred samples

are sputum or tracheal

aspirate, if not feasible,

then nasopharyngeal

swab

4- In a single room with

HEPA filter, HCW to

wear fitted N95, eye

protection, gloves and

gown