respiratory Abdrabalnabi d Infection Control Unit Johns Hopkins Aramco Healthcare Dhahran Saudi Arabia Conclusions There was a signi cant increase in the utilization of surgical masks respirators soap and alco hol based hand sanitizers Such an increase is a challenge and adds cost to the health care system 2018 Association for Professionals in Infection Control and Epidemiology Inc Published by Elsevier Inc All rights reserved Key Words MERS Personal Protective Equipment Cost Economic impact Healthcare WorldHealthOrganizationfrom27countries withanoverallcasefatality s During the severe requirements were not known although there was a known health care set the preparedness on the impact of hin hospitals 9 10 Here we study the infection control in uence of MERS CoV by ARTICLE IN PRESS American Journal of Infection Control 000 2018 1 4 Contents lists available American Journal of w trol burdens on affected health care facilitie rateof35 6 3 MostcasesofMERS CoVhavebeenreportedintheArabian Peninsula withKSAhavingthemajorityofreportedcases 4 MERS CoV causes multiple outbreaks within and outside Saudi Arabia 4 Such outbreaks may cause economic and infection con need to increase infection control capacity in tings 8 Although a few articles have addressed of hospitals to face MERS there are no data MERS CoV on infection control resources wit Middle East respiratory syndrome coronavirus MERS CoV emerged in June 2012 in the Kingdom of Saudi Arabia KSA 1 and the rst health care associated MERS infection was described in multiple facilities in Al Hasa KSA 2 Since then a total of 2 229 cases have been reported to the Spanish in uenza these situations resulted in additional costs of 25 000 99 000 when no alert was present to as high as 1 537 000 for SARS during an orange alert level 6 During the ini tial years of MERS CoV outbreaks the exact infection control 7 acute respiratory syndrome SARS outbreak great impact on infection control measures involving outbreaks of SARS 2009 pandemic Address correspondence to Jaffar A Al Taw q MD Johns Hopkins Aramco Healthcare PO Box 11705 Dhahran E mail address jaltaw J A Al Taw q Con icts of interest None to report https doi org 10 1016 j ajic 2018 09 015 0196 6553 2018 Association for Professionals in Infection Background Middle East respiratory syndrome coronavirus MERS CoV caused multiple outbreaks Such outbreaks increase economic and infection control burdens We studied the infection control in uence of MERS CoV using a hospital based analysis Methods Our hospital had 17 positive and 82 negative cases of MERS CoV between April 1 2013 and June 3 2013 The study evaluated the impact of these cases on the use of gloves surgical masks N95 respirators alcohol based hand sanitizer and soap as well as hand hygiene compliance rates Results During the study the use of personal protective equipment during MERS CoV compared with the period before MERS CoV increased dramatically from 2 947 4 to 10 283 9 per 1 000 patient days P 0000001 for surgical masks and from 22 to 232 per 1 000 patient days P 0000001 for N95 masks The use of alcohol based hand sanitizer and soap showed a signi cant increase in utilized amount P 0000001 Hand hygiene compliance rates increased from 73 just before the occurrence of the rst MERS case to 88 during MERS cases P 0001 The monthly added cost was 16 400 for included infection control items the disease had a 5 In a simulation H1N1 and 1918 analyzing data on speci c infection control parameters using a hospital based analysis METHODS Our hospital was the rst outside the United States to be accredited by the Joint Commission and to subsequently main tain accreditation by the Joint Commission International The Specialty Internal Medicine 31311 Saudi Arabia Control and Epidemiology Inc Published by Elsevier Inc All rights reserved b Indiana University School of Medicine Indianapolis IN USA c Johns Hopkins University School of Medicine Baltimore MD USA Major Article Infection control in uence of Middle East coronavirus A hospital based analysis D1X XJaffar A Al Taw q MD FACP FRCPE FRCPLD2X X a b c D3X XRana D7X XShantymole Mathew RND8X X d D9X XKamal Abdul Rahman RND10X X d a Specialty Internal Medicine Johns Hopkins Aramco Healthcare Dhahran Saudi Arabia journal homepage syndrome RN MPHD4X X d D5X XAlla Taher RND6X X d ww ajicjournal org at ScienceDirect Infection Control organization has state of the art infection control practices and procedures The hospital was one of the rst in the world to deal with MERS CoV cases when 99 patients who met the case de nition of suspected MERS CoV were admitted Of those cases 17 tested positive and 82 tested negative for MERS CoV between April 1 2013 and June 3 2013 11 13 Of the positive cases as described previously 30 had health care associated infections because the hospital received patients in transfer from other facilities 2 In this study we aimed to re evaluate the impact of these cases on infection control practices including the use of gloves surgical masks N95 respirators alcohol based hand sanitizer and soap expressed as mL per 1 000 patient days Data on the monthly use of gloves pairs surgical masks and N95 respirators were obtained from the central supply ser vice assessed based on retrospective analysis of overall supply ordering by the hospital and expressed per 1 000 patient days We also evaluated any change in monthly hand hygiene compli ance rates The data span from May 2012 to July 2013 and include the pre MERS period May 2012 to March 2013 the MERS period April to May 2013 and the post MERS period June to July 2013 Data were extracted from the infection con in Figure 2 there was a signi cant increase in the used amount P 0001 Fig 3 The monthly added cost was 16 400 for the included infection control items such as hand sanitizers soap surgi cal masks and N95 respirators DISCUSSION In the most recent updates by the World Health Organization a total of 2 040 31 cases were health care facility associated infections 14 In addition initial MERS CoV symptoms tend to be nonspeci c and might not be noticed Thus adherence to stan dard precautions is a critical factor in the prevention of MERS CoV transmission 14 This adherence as well as the initial uncer tainty about transmission routes early in the course of the dis ease had resulted in widespread fear of MERS CoV It is known that application of standard infection control results in the termi nation of MERS CoV outbreaks 2 4 15 16 Here we showed a signi cant increase in the use of PPE mainly surgical masks respirators alcohol based hand sanitizer and soap There was a signi cant increase in the utilization of surgical masks and respi rators during the study period There are mixed recommendations ARTICLE IN PRESS 2 J A Al Taw q et al American Journal of Infection Control 00 2018 1 4 P 0000001 Handhygiene complianceratesareshowninFigure 2 The hand hygiene compliance rate increased from 73 just before the occurrence of the rst MERS case to 88 during MERS cases trol database and monthly patient days were obtained from the health information unit This study was approved by the institu tional review board of the Johns Hopkins Aramco Healthcare RESULTS During the observation period the utilization of personal protec tive equipment PPE with cases of MERS CoV compared with the period before MERS CoV cases increased dramatically from 2 947 4 to 10 283 9 per 1 000 patient days P 0000001 for surgical masks and from 22 to 232 per 1 000 patient days P 0000001 for N95 masks Fig 1 It is interesting to note that the increase in utilization of N95 masks preceded the increase in surgical mask utilization by about 1 month The utilization of alcohol based hand sanitizer and soap is shown Fig 1 A run chart showing the utilization of surgical masks solid line and respirators dashed March 2013 and during Middle East respiratory syndrome cases April to July 2013 for the care of patients with MERS CoV with regard to placing patients in airborne isolation and thus the use of N95 respirators droplet precautions and surgical masks 7 15 17 18 The use of surgi cal masks was noted to increase signi cantly during the 2009 H1N1 in uenza pandemic with a reported 52 increase in use 19 This increase in the use of PPE is paralleled by an increase in cost It is recommended that hospitals maintain an adequate sup ply of PPE for use during infectious disease outbreaks In 1 study it was calculated that 4 sets of PPE N95 respirators double gloves gowns and goggles per day are needed for each health care worker in the high risk group and 2 sets of PPE are required for medium and low risk groups 20 Another implication for the increased use of PPE is the generation of medical waste which we did not address in this study In 1 simulation exercise an additional 570 L of waste was generated per day 21 We were not able to show a signi cant increase in hand hygiene practices despite the signi cant increase in utilization of alcohol based hand sanitizers This observation may be related to the fact that baseline hand hygiene was about 88 in the preceding months However the hand hygiene compliance line in the period before Middle East respiratory syndrome cases May 2012 to rate dropped to 73 just before the occurrence of the rst MERS caseandthenpickedupto88 P 0001 It has been shown that both observation and a multifaceted approach increase hand hygiene compliance 22 23 and that utilization of secret limitations of the study include the fact that the presented data are small and represent only one non Ministry of Health hospital anditwasnotpossibletousethedatatodrawconclusions regarding a national estimate of disease burden There are multi Fig 2 A run chart showing the utilization of alcohol based hand sanitizers solid line and soap dashed line in the period before Middle East respiratory syndrome cases May 2012 to March 2013 and during Middle East respiratory syndrome cases April to July 2013 ARTICLE IN PRESS J A Al Taw q et al American Journal of Infection Control 00 2018 1 4 3 shoppersmaygiveafalsesenseoftheactualratesofhand hygiene compliance 24 Another possible explanation is that the utilized soap and hand sanitizer may have been used by patients and visitors Although the data are from 2013 which may be considered a limitation they are still valid because this is the only study docu menting the burden of this new virus on health infrastructure even though 5 years have elapsed since its emergence Other Fig 3 A run chart showing hand hygiene compliance rates in the period before Middle East tory syndrome cases April to July 2013 UCL Upper Control Limits LCL lower control limits ple hospitals supervised by the Ministry of Health in addition to other hospitals supervised by various institutions and the private sector CONCLUSIONS There was a signi cant increase in the utilization of surgical masks respirators soap and alcohol based hand sanitizers during respiratory syndrome cases May 2012 to March 2013 and during Middle East respira the study period Such an increase is a challenge and adds cost to the health care system References 1 Zaki AM van Boheemen S Bestebroer TM Osterhaus ADME Fouchier RAM Isola tion of a novel coronavirus from a man with pneumonia in Saudi Arabia N Engl J Med 2012 367 1814 20 2 Assiri A McGeer A Perl TM Price CS Al Rabeeah AA Cummings DAT et al Hospi tal outbreak of Middle East respiratory syndrome coronavirus N Engl J Med 2013 369 407 16 3 World Health Organization Middle East respiratory syndrome coronavirus MERS CoV Available from http www who int emergencies mers cov en Accessed October 8 2018 4 Al Taw q JA Auwaerter PG Healthcare associated infections the hallmark of Middle East respiratory syndrome coronavirus with review of the literature J Hosp Infect 2018 Jun 1 Epub ahead of print 5 Shaw K The 2003 SARS outbreak and its impact on infection control practices Public Health 2006 120 8 14 6 Dan YY Tambyah PA Sim J Lim J Hsu LY Chow WL et al Cost effectiveness analy sis of hospital infection control response to an epidemic respiratory virus threat Emerg Infect Dis 2009 15 1909 16 7 Memish ZA Al Taw q JA Middle East respiratory syndrome coronavirus infection control the missing piece Am J Infect Control 2014 42 1258 60 8 Maltezou HC Tsiodras S Middle East respiratory syndrome coronavirus implica tions for health care facilities Am J Infect Control 2014 42 1261 5 9 Butt TS Koutlakis Barron I AlJumaah S AlThawadi S AlMofada S Infection control and prevention practices implemented to reduce transmission risk of Middle East respiratory syndrome coronavirus in a tertiary care institution in Saudi Arabia Am J Infect Control 2016 44 605 11 10 Al Taw q JA Rothwell S Mcgregor HA Khouri ZA A multi faceted approach of a nursing led education in response to MERS CoV infection J Infect Public Health 2018 11 260 4 11 Al Taw q JA Hinedi K Ghandour J Khairalla H Musleh S Ujayli A et al Middle East respiratory syndrome coronavirus MERS CoV a case control study of hos pitalized patients Clin Infect Dis 2014 59 160 5 12 Al Taw q JA Hinedi K Abbasi S Babiker M Sunji A Eltigani M Hematologic hepatic and renal function changes in hospitalized patients with Middle East respiratory syndrome coronavirus Int J Lab Hematol 2017 39 272 8 13 Al Taw q JA Rabaan AA Hinedi K In uenza is more common than Middle East respiratory syndrome coronavirus MERS CoV among hospitalized adult Saudi patients Travel Med Infect Dis 2017 20 56 60 14 World Health Organization WHO MERS CoV global summary and assessment of risk Available from http www who int emergencies mers cov risk assess ment july 2017 pdf ua 1 Accessed October 8 2018 15 Al Taw q JA Perl TM Middle East respiratory syndrome coronavirus in healthcare settings Curr Opin Infect Dis 2015 28 392 6 16 El Bushra HE Al Arbash HA Mohammed M Abdalla O Abdallah MN Al Mayahi ZK et al Outcome of strict implementation of infection prevention control meas ures during an outbreak of Middle East respiratory syndrome Am J Infect Control 2017 45 502 7 17 Al Taw q JA Memish ZA Infection control measures for the prevention of MERS coronavirus transmission in healthcare settings Expert Rev Anti Infect Ther 2016 14 281 3 18 Al Taw q JA Memish ZA Managing MERS CoV in the healthcare setting Hosp Pract 1995 2015 43 158 63 19 Rexroth U Buda S Occupational health and practice management of primary care practitioners during in uenza pandemic 2009 10 in Germany a survey of 1150 physicians participating in syndromic in uenza surveillance at Robert Koch Insti tute Gesundheitswesen 2014 76 670 5 20 Hashikura M Kizu J Stockpile of personal protective equipment in hospital set tings preparedness for in uenza pandemics Am J Infect Control 2009 37 703 7 21 Phin NF Rylands AJ Allan J Edwards C Enstone JE Nguyen Van Tam JS Personal protective equipment in an in uenza pandemic a UK simulation exercise J Hosp Infect 2009 71 15 21 22 Al Taw q JA Abed MS Al Yami N Birrer RB Promoting and sustaining a hospital wide multifaceted hand hygiene program resulted in signi cant reduction in health care associated infections Am J Infect Control 2013 41 482 6 23 Al Taw q JA Treble M Abdrabalnabi R Okeahialam C Khazindar S Myers S Using targeted solution tools as an initiative to improve hand hygiene challenges and lessons learned Epidemiol Infect 2018 146 276 82 24 El Saed A Noushad S Tannous E Abdirizak F Arabi Y Al Azzam S et al Quantifying the Hawthorne effect using overt and covert observation of hand hygiene at a tertiary care hospital in Saudi Arabia Am J Infect Control 2018 46 930 5 ARTICLE IN PRESS 4 J A Al Taw q et al American Journal of Infection Control 00 2018 1 4