Middle East Respiratory Syndrome Coronavirus, Saudi Arabia, 2017-2018.

We characterized exposures and demographics of Middle East respiratory syndrome coronavirus cases reported to the Saudi Arabia Ministry of Health during July 1-October 31, 2017, and June 1-September 16, 2018. Molecular characterization of available specimens showed that circulating viruses during these periods continued to cluster within lineage 5.

Acute viral respiratory infections among children in MERS-endemic Riyadh, Saudi Arabia, 2012-2013.

The emergence of the Middle East Respiratory Syndrome (MERS) in Saudi Arabia has intensified focus on Acute Respiratory Infections [ARIs]. This study sought to identify respiratory viruses (RVs) associated with ARIs in children presenting at a tertiary hospital. Children (aged ≤13) presenting with ARI between January 2012 and December 2013 tested for 15 RVs using the SeeplexR RV15 kit were retrospectively included. Epidemiological data was retrieved from patient records. Of the 2235 children tested, 61.5% were ≤1 year with a male: female ratio of 3:2. Viruses were detected in 1364 (61.02%) children, 233 (10.4%) having dual infections: these viruses include respiratory syncytial virus (RSV) (24%), human rhinovirus (hRV) (19.7%), adenovirus (5.7%), influenza virus (5.3%), and parainfluenzavirus-3 (4.6%). Children, aged 9-11 months, were most infected (60.9%). Lower respiratory tract infections (55.4%) were significantly more than upper respiratory tract infection (45.3%) (P < 0.001). Seasonal variation of RV was directly and inversely proportional to relative humidity and temperature, respectively, for non MERS coronaviruses (NL63, 229E, and OC43). The study confirms community-acquired RV associated with ARI in children and suggests modulating roles for abiotic factors in RV epidemiology. However, community-based studies are needed to elucidate how these factors locally influence RV epidemiology. J. Med. Virol. 89:195-201, 2017. © 2016 Wiley Periodicals, Inc.

Molecular Epidemiology of Hospital Outbreak of Middle East Respiratory Syndrome, Riyadh, Saudi Arabia, 2014.

We investigated an outbreak of Middle East respiratory syndrome (MERS) at King Fahad Medical City (KFMC), Riyadh, Saudi Arabia, during March 29-May 21, 2014. This outbreak involved 45 patients: 8 infected outside KFMC, 13 long-term patients at KFMC, 23 health care workers, and 1 who had an indeterminate source of infection. Sequences of full-length MERS coronavirus (MERS-CoV) from 10 patients and a partial sequence of MERS-CoV from another patient, when compared with other MERS-CoV sequences, demonstrated that this outbreak was part of a larger outbreak that affected multiple health care facilities in Riyadh and possibly arose from a single zoonotic transmission event that occurred in December 2013 (95% highest posterior density interval November 8, 2013-February 10, 2014). This finding suggested continued health care-associated transmission for 5 months. Molecular epidemiology documented multiple external introductions in a seemingly contiguous outbreak and helped support or refute transmission pathways suspected through epidemiologic investigation.

Characterisation of MRSA strains isolated from patients in a hospital in Riyadh, Kingdom of Saudi Arabia.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is spreading worldwide and poses a serious public health problem, being present in hospital settings and communities. However, from the Middle East and the Arabian Peninsula few molecular typing data on MRSA strains are currently available. In order to obtain data on the population structure of MRSA in Riyadh, Saudi Arabia, 107 clinical and environmental MRSA isolates were genotyped using a microarray-based assay. RESULTS: Five major MRSA strains from four clonal complexes were identified CC8/ST239-III (20.75%), PVL-positive as well as -negative CC22-IV (18.87% and 9.43%, respectively), PVL-positive CC30-IV (12.26%) and PVL-positive CC80-IV (17.92%). Minor strains, which accounted for less than 3% each, included CC1-IV/SCCfus, PVL-positive CC1/ST772-V, PVL-positive as well as- negative CC5-IV, CC5-IV/SCCfus, CC5-V, CC6-IV, CC45-IV, PVL-negative CC80-IV, PVL-positive CC88-IV, CC97-V and a CC9/ST834-MRSA strain. CONCLUSIONS: Typing of MRSA strains from Riyadh revealed a high diversity of clonal complexes. The prevalence of the genes encoding the Panton-Valentine leukocidin was surprisingly high (54.21%), and a significant rate of resistance markers was detected also in strains considered as community-associated.

The current challenges affecting the quality of care of HIV/AIDS in the Middle East: Perspectives from local experts and future directions.

OBJECTIVE: This report aimed to reflect the experts' views regarding the challenges affecting the quality of care for people living with HIV in the Middle East. Besides, we integrated experts' opinions and recommendations to offer future directions to improve the quality of care and the overall landscape of HIV in the Middle East. METHODS: This review article is based on a comprehensive literature search and the outcomes of several regional meetings that discussed the challenges faced by patients living with HIV in the Middle East. RESULTS: The experts called for actions by various stakeholders to improve the quality of HIV care and implement culturally acceptable programs to face the ongoing stigma and discrimination. Various strategies should also be implemented to improve the HIV awareness among the general population and medical staff, prompt early diagnosis and initiation of ART,and optimize patients' adherence to treatment. Besides, reliable databases, both on national and regional scales, should be implemented to provide reliable data regarding the HIV status in the region. CONCLUSION: All efforts should be directed towards achieving the UNAIDS the "90-90-90" targets, with an acceptable quality of life and minimal complications.

Epidemiological and clinical features of COVID-19 patients in Saudi Arabia.

BACKGROUND: The aim of this study is to describe the clinical and demographic characteristics of COVID-19 patients, and the risk factors associated with death in Saudi Arabia to serve as a reference to further understand this pandemic and to help in the future decisions and control of this global crisis. METHODS: This multicenter, retrospective, observational, cross-sectional study was conducted on 240,474 patients with confirmed COVID-19 in Saudi Arabia. Data was collected retrospectively through the Health Electronic Surveillance Network at the Ministry of Health. Patients were classified based on their outcome as recovered, dead, or active with no definite outcome. We must specify the date period. RESULTS: As of 20th of June 2020, 79.7% of COVID-19 cases were young and middle-aged, ranging between 20-59 years. There was evidently a difference in the sex ratio, where males constituted 71.7% of cases. The majority were non-Saudi nationals, representing 54.7% of cases. Furthermore, the contraction of COVID-19 was travel-related in 45.1% of cases. Signs and symptoms were reported in 63% of cases, the most common of which were fever; 85.2%, and cough; 85%. Deaths occurred more frequently in patients 40-49 years, 50-59 years, and 60-69 years, representing 19.2%, 27.9%, and 21.3% of deaths, respectively. Additionally, the case fatality rate (CFR) was higher in older age-groups, reaching 10.1% in those ≥80 years. Moreover, the CFR of males was higher than that of females, with 0.95% and 0.62%, respectively. As for nationality, Saudis had a CFR of 0.46% versus 1.19% in non-Saudis. CONCLUSION: The total number of positive COVID-19 cases detected constitute 0.7% of the Saudi population to date. Older age, non-Saudi nationalities, being male, travelling outside Saudi Arabia, and the presence of symptoms, as opposed to being asymptomatic were considered risk factors and found to be significantly more associated with death in patients with COVID-19.

Clinical characteristics of COVID-19 in Saudi Arabia: A national retrospective study.

BACKGROUND: The global battle to contain the novel coronavirus disease 2019 (COVID-19) pandemic rages on. Previous studies described the clinical characteristics of COVID-19, but knowledge gaps remain in the Middle East region. Identifying these features will help in mapping the disease and guiding pandemic management. A multi-center, retrospective cross-sectional study was initiated to describe the demographic data, clinical characteristics, and outcomes of COVID-19 cases across all the regions of Saudi Arabia. METHODS: The analysis included all laboratory-confirmed positive COVID-19 patients from the 1st of March 2020 to 31st of March 2020 across all regions of Saudi Arabia. Demographic data, clinical characteristics, incubation periods, laboratory findings, and patient outcomes data were retrieved from 1519 cases in the Health Electronic Surveillance Network Database. RESULTS: The median age was 36 years and 54.3% (n = 825) of the patients were men. Patients working in health care facilities represented 12.5% of the cases (n = 190) and 9.3% of cases were asymptomatic. The median incubation period was 6 days. The most common symptoms were cough (89.4%), fever (85.6%), and sore throat (81.6%); 20.1% of the patients had underlying comorbidities. Hypertension was seen in 8.8% and diabetes in 7.6% of all the cases. The percentage of cases with temperatures >38Ö¯C was 20.3% (n = 129), and 1.6% of patients had heart rates ≥125 beats/min and 4.7% of them had respiratory rates of >24 breaths/min. Lymphocytopenia occurred in 37.5% of cases. Overall, 71.6% of patients were admitted to hospitals and 4.7% required ICU treatment. We could not completely assess the clinical courses or final outcomes of COVID-19 patients. CONCLUSION: In this multi-center retrospective study, fever and cough were common symptoms. Special attention should be addressed toward asymptomatic carriers and workers in health care facilities as they play a key role in disease transmission.

Hospital-based surveillance of influenza A(H1N1)pdm09 virus in Saudi Arabia, 2010-2016.

BACKGROUND: Influenza is a highly contagious acute viral respiratory tract infection. The emergence of influenza A(H1N1)pdm09 in 2009 caused a pandemic. Since then it has become a seasonal influenza virus. It causes symptoms ranging from mild to severe illness, which might be fatal, particularly in people with underlying chronic medical conditions, immunocompromised people, the elderly, and pregnant women. OBJECTIVE: Describe the data generated by the influenza A(H1N1) pdm09 surveillance in Saudi Arabia from 2010 to 2016. DESIGN: Retrospective, descriptive. SETTING: Hospitals reporting to the Ministry of Health. MATERIALS AND METHODS: We studied aggregate data on hospitalized cases of influenza A(H1N1)pdm09 in Saudi Arabia between 2010 and 2016. The surveillance system used the case definition proposed by the WHO. The cases were confirmed by performing the real-time PCR (polymerase chain reaction) on upper respiratory samples. MAIN OUTCOME MEASURES: Suspected and confirmed influenza A(H1N1)pdm09 cases. SAMPLE SIZE: 113 502 suspected H1N1 cases and 17 094 (15.1%) confirmed cases. RESULTS: Most of the reported cases were registered in the Riyadh region. During the period of the study, the highest number of confirmed cases, 9262 (54.2 %), was in 2015. The case fatality rate for confirmed cases was 3.6%. CONCLUSION: Influenza A(H1N1)pdm09 showed seasonal trends. The number of suspected influenza cases each year was proportionate to the number of confirmed cases for that year. Riyadh, Jeddah and the Eastern areas (regions with the highest population) reported most of the cases. LIMITATION: Only one strain of H1N1 was tested. CONFLICT OF INTEREST: None.

The Global Meningococcal Initiative meeting on prevention of meningococcal disease worldwide: Epidemiology, surveillance, hypervirulent strains, antibiotic resistance and high-risk populations.

INTRODUCTION: The 2018 Global Meningococcal Initiative (GMI) meeting focused on evolving invasive meningococcal disease (IMD) epidemiology, surveillance, and protection strategies worldwide, with emphasis on emerging antibiotic resistance and protection of high-risk populations. The GMI is comprised of a multidisciplinary group of scientists and clinicians representing institutions from several continents. AREAS COVERED: Given that the incidence and prevalence of IMD continually varies both geographically and temporally, and surveillance systems differ worldwide, the true burden of IMD remains unknown. Genomic alterations may increase the epidemic potential of meningococcal strains. Vaccination and (to a lesser extent) antimicrobial prophylaxis are the mainstays of IMD prevention. Experiences from across the globe advocate the use of conjugate vaccines, with promising evidence growing for protein vaccines. Multivalent vaccines can broaden protection against IMD. Application of protection strategies to high-risk groups, including individuals with asplenia, complement deficiencies and human immunodeficiency virus, laboratory workers, persons receiving eculizumab, and men who have sex with men, as well as attendees at mass gatherings, may prevent outbreaks. There was, however, evidence that reduced susceptibility to antibiotics was increasing worldwide. EXPERT COMMENTARY: The current GMI global recommendations were reinforced, with several other global initiatives underway to support IMD protection and prevention.

Scope and extent of healthcare-associated Middle East respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in Riyadh, Saudi Arabia, 2017.

OBJECTIVE: To investigate a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak event involving multiple healthcare facilities in Riyadh, Saudi Arabia; to characterize transmission; and to explore infection control implications. DESIGN: Outbreak investigation. SETTING: Cases presented in 4 healthcare facilities in Riyadh, Saudi Arabia: a tertiary-care hospital, a specialty pulmonary hospital, an outpatient clinic, and an outpatient dialysis unit. METHODS: Contact tracing and testing were performed following reports of cases at 2 hospitals. Laboratory results were confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) and/or genome sequencing. We assessed exposures and determined seropositivity among available healthcare personnel (HCP) cases and HCP contacts of cases. RESULTS: In total, 48 cases were identified, involving patients, HCP, and family members across 2 hospitals, an outpatient clinic, and a dialysis clinic. At each hospital, transmission was linked to a unique index case. Moreover, 4 cases were associated with superspreading events (any interaction where a case patient transmitted to ≥5 subsequent case patients). All 4 of these patients were severely ill, were initially not recognized as MERS-CoV cases, and subsequently died. Genomic sequences clustered separately, suggesting 2 distinct outbreaks. Overall, 4 (24%) of 17 HCP cases and 3 (3%) of 114 HCP contacts of cases were seropositive. CONCLUSIONS: We describe 2 distinct healthcare-associated outbreaks, each initiated by a unique index case and characterized by multiple superspreading events. Delays in recognition and in subsequent implementation of control measures contributed to secondary transmission. Prompt contact tracing, repeated testing, HCP furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission.

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.

Middle East Respiratory syndrome (MERS) first emerged in Saudi Arabia in 2012 and remains a global health concern. The objective of this study was to compare the clinical features and risk factors for adverse outcome in patients with RT-PCR confirmed MERS and in those with acute respiratory disease who were MERS-CoV negative, presenting to the King Fahad Medical City (KFMC) in Riyadh between October 2012 and May 2014. The demographics, clinical and laboratory characteristics and clinical outcomes of patients with RT-PCR confirmed MERS-CoV infection was compared with those testing negative MERS-CoV PCR. Health care workers (HCW) with MERS were compared with MERS patients who were not health care workers. One hundred and fifty nine patients were eligible for inclusion. Forty eight tested positive for MERS CoV, 44 (92%) being hospital acquired infections and 23 were HCW. There were 111 MERS-CoV negative patients with acute respiratory illnesses included in this study as "negative controls". Patient with confirmed MERS-CoV infection were not clinically distinguishable from those with negative MERS-CoV RT-PCR results although diarrhoea was commoner in MERS patients. A high level of suspicion in initiating laboratory tests for MERS-CoV is therefore indicated. Variables associated with adverse outcome were older age and diabetes as a co-morbid illness. Interestingly, co-morbid illnesses other than diabetes were not significantly associated with poor outcome. Health care workers with MERS had a markedly better clinical outcome compared to non HCW MERS patients.

Lemierre's syndrome due to Klebsiella pneumoniae in a 63-year-old man with diabetes: a case report.

INTRODUCTION: Lemierre's syndrome was originally documented to be caused by Fusobacterium necrophorum. It is a very rare condition with a prevalence of one to 14.4 instances per million. Its presentation is varied, not only in composition but also in the infecting organism. Treatment with anticoagulants has been controversial and applied only on a case-by-case basis. CASE PRESENTATION: A 63-year-old Saudi man who had had uncontrolled diabetes mellitus for 47 years presented to our facility with a five-day history of swelling on the right side of his neck and fever. The swelling progressively increased in size and was associated with pain, dysphagia, odynophagia, change of voice ('hot potato voice'), and reduced appetite. Abscess content culture and sensitivity testing revealed Klebsiella pneumoniae. However, blood culture results were repeatedly negative. The abscess was incised and drained without any complication. Our patient was treated with clindamycin and cefuroxime. Warfarin was also administered concurrently for six weeks, for an isolated internal jugular vein thrombosis (IJV), with complete resolution of the thrombus. Normoglycemia was achieved and our patient was discharged after complete wound healing and the return of his biochemical parameters to normal. CONCLUSIONS: Only two cases of Lemierre's syndrome in patients with diabetes due to K. pneumoniae have been reported previously. A review of the literature suggested that an association exists between deep neck infections due to K. pneumoniae and diabetes mellitus. The reasons for this association are still not clear. This poses a question as to whether diabetes mellitus specifically predisposes these patients to infection with this organism. It is suggested that clinicians should consider infectious agents other than F. necrophorum in the causation of Lemierre's syndrome, especially in patients with diabetes.

Septic arthritis due to Mycobacterium szulgai in a patient with human immunodeficiency virus: case report.

Mycobacterium szulgai is a rare human pathogen that mainly causes pulmonary diseases. We report the first case of M. szulgai causing septic arthritis in a patient with human immunodeficiency virus. A culture from the joint aspiration was needed to isolate and identify this organism. The patient was treated successfully with ciprofloxacin, clarithromycin, and ethambutol.