On Monday April 28, emergency department staff at Community Hospital in Munster, Ind., examined a male patient who complained of severe flu-like symptoms, including shortness of breath, coughing, a rising fever and excess sinus drainage.
A combination of well-designed hospital protocols, heads-up staff work, technological aids, collaboration between hospital officials, state and federal public health authorities—and some luck—led to the patient being quickly identified as the first U.S. case of Middle East respiratory syndrome
and the virus being contained. Public health
officials have been watching for MERS since it first appeared on the Arabian Peninsula two years ago.
Community Hospital is a 429-bed facility and part of the three-hospital, not-for-profit Community Healthcare System in northwest Indiana
. The hospital is located about 50 miles southeast of Chicago's O'Hare International Airport in the small town of Munster, and hospital staff are accustomed to treating American and international patients who have just come from foreign countries. They routinely ask patients about their travel history.
Well-designed protocols, heads-up staff, technological aids and good collaboration with public health authorities — and some luck — led to the patient being quickly diagnosed and the MERS virus being contained.
They found out that the patient flew on April 24 from the Saudi Arabian capital of Riyadh to London and then to Chicago, where he caught a bus to Indiana to visit his family. A few days later, he experienced severe respiratory symptoms and went to the hospital's ED, which admitted him the same day. His name was not released.
“The key is getting that travel history right up front,” said Dr. Daniel Feikin, an epidemiologist at the Centers for Disease Control and Prevention
who is leading the investigation of the case. “And then as soon as you suspect MERS, even before you do the testing, you should make sure that you have that patient on isolation precaution so you don't spread it to any other patients or healthcare workers.”
If a patient has returned within the past 14 days from the Arabian Peninsula and has a febrile respiratory illness, providers should consider testing for MERS, he advised.
A key factor that prevented spread of the virus in the Indiana case is that patients who enter the Community Hospital's ED with certain symptoms are routinely kept in private triage rooms, said Dr. Alan Kumar, chief medical information officer for the hospital. This patient was placed in a negative air flow room, where air is drawn up and out of the hospital through a special ventilation system. “Had we not done the things that we're used to doing every day, it could have been a lot worse,” he said.
The day after he was admitted, the patient was interviewed by the hospital's infectious disease team, who asked him about his travel history. “We learned information that presented a risk,” Kumar said. The infectious disease specialists were knowledgeable about MERS from the medical literature, as well as from MERS guidance on the CDC website (cdc.gov/coronavirus/mers
). When they integrated the patient's symptoms, travel history and their medical knowledge about the virus, they suspected MERS.
Five days in Munster, Ind.APRIL 28
Patient visits emergency department of Community Hospital in Munster,is admitted and isolated in negative air-flow room.APRIL 29
Infectious disease team interviews patient, asks about travel history and suspects MERS. APRIL 30
Patient virus samples sent to Indiana State Health Department; hospital reviews which staffers had contact with the patient.MAY 1
State Health Department confirms positive results for MERS DNA, overnights isolates to CDC in Atlanta.MAY 2
CDC confirms first U.S. case of MERS; CDC investigators arrive in Munster. Exposed hospital staff tested and placed on 14-day home stay for observation.
Respiratory fluid specimens were taken from the patient and sent to the Indiana State Health Department on April 30 for a polymerase chain-reaction test. The test, provided by the CDC, can identify a small piece of DNA or the distinct signature of the MERS virus. On May 1, the State Health Department confirmed the test was positive and isolates of the virus were overnighted to CDC headquarters in Atlanta.
As the infectious disease team waited for results from the CDC, hospital leaders were notified. They looked at electronic health records
and pulled surveillance video from the ED for the 24-hour period before the patient was placed in isolation to find out who else might have been exposed. They also pulled logs of tracer tags worn by staff from a GPS system installed in 2009 to monitor workflow. The system enables the hospital to identify the location of individual staff members.
The logs showed that nearly 50 staffers had come into contact with the patient and tracked how much time each person had spent with him. Those staffers were placed on home isolation on May 2 as soon as MERS was officially confirmed by the CDC. They are being followed for the 14-day incubation period. None have tested positive for the virus, and they are expected to return to work by May 16.
“Operationally, it was hugely important to be able to understand workflow,” said Don Fesko, CEO of the hospital. “We could easily take anyone who was on duty out of duty, and quickly explain to them what was going on.”
As soon as the CDC confirmed the case as MERS and alerted the hospital, six CDC investigators were dispatched to Munster. “Honestly, we've been expecting this to happen for over a year,” Feikin said.
The viral respiratory disease was first reported in Saudi Arabia in 2012. Little is known about the condition, but it tends to spread through close contact. Patients develop fever, cough and shortness of breath within 14 days following exposure. There have been a total of 496 laboratory-confirmed cases, according to the World Health Organization, including 229 reported between April 11 and May 4. The number of deaths is estimated at more than 110. All cases have originated from six countries in the Arabian Peninsula, according to the CDC. There is no definitive treatment. MERS has been most prevalent among the elderly, healthcare workers and those with other comorbidities. Research into potential antivirals and vaccines is underway, the CDC said.
Get an inside look at an Indiana hospital's response to the first U.S. appearance of the MERS virus in our video report at modernhealthcare.com/mers-video
.First U.S. MERS patient released from Indiana hospital
On May 6, most members of the CDC team sent to investigate the case returned home. But the CDC's MERS surveillance efforts continue. The agency warned that future U.S. cases are inevitable. “If you're a hospital in a big metropolitan area, where a lot of world travelers are coming in, then you should probably have your antenna up,” Feikin said. “But it is possible that MERS could show up in any hospital in any place in the United States.”
The MERS patient at Community Hospital was released Friday. Tests by the CDC and the state's health department confirmed the patient is now negative for the virus and free to travel, health officials said. At the end of the hospital employees' incubation period, they will be retested to confirm that they are negative for MERS.
“We followed the protocols,” Kumar said, “and it worked wonderfully in this case.”Follow Sabriya Rice on Twitter: @MHsrice