An outbreak of Middle East Respiratory Syndrome (MERS) due to coronavirus in Al-Ahssa Region, Saudi Arabia, 2015.

Between 19 April and 23 June 2015, 52 laboratory-confirmed cases of Middle East Respiratory Syndrome due to coronavirus (MERS) were reported from Al-Ahssa region, eastern Saudi Arabia. The first seven cases occurred in one family; these were followed by 45 cases in three public hospitals. The objectives of this investigation were to describe the epidemiological characteristic of the cluster and identify potential risk factors and control measures to be instituted to prevent further occurrence of MERS. We obtained the medical records of all confirmed cases, interviewed the members of the affected household and reviewed the actions taken by the health authorities. All the cases were connected. The index case was a 62-year-old man with a history of close contact with dromedary camels; three of the seven infected family members and 18 people in hospitals died (case-fatality rate, 40.4%). The median incubation period was about 6 days. The cluster of cases appeared to be due to high exposure to MERS, delayed diagnosis, inadequate risk communication and inadequate compliance of hospital health workers and visitors with infection prevention and control measures.

An outbreak of Middle East Respiratory Syndrome (MERS) due to coronavirus in Al-Ahssa Region, Saudi Arabia, 2015

Between 19 April and 23 June 2015, 52 laboratory-confirmed cases of Middle East Respiratory Syndrome due to coronavirus [MERS] were reported from Al-Ahssa region, eastern Saudi Arabia. The first seven cases occurred in one family; these were followed by 45 cases in three public hospitals. The objectives of this investigation were to describe the epidemiological characteristic of the cluster and identify potential risk factors and control measures to be instituted to prevent further occurrence of MERS. We obtained the medical records of all confirmed cases, interviewed the members of the affected household and reviewed the actions taken by the health authorities. All the cases were connected. The index case was a 62-year-old man with a history of close contact with dromedary camels; three of the seven infected family members and 18 people in hospitals died [case-fatality rate, 40.4%]. The median incubation period was about 6 days. The cluster of cases appeared to be due to high exposure to MERS, delayed diagnosis, inadequate risk communication and inadequate compliance of hospital health workers and visitors with infection prevention and control measures

Entre le 19 avril et le 23 juin 2015, 52 cas confirmés en laboratoire de syndrome respiratoire du Moyen-Orient [MERS] causé par le coronavirus ont été notifiés dans la région d'Al-Ahssa, partie orientale de l'Arabie saoudite. Les sept premiers cas sont survenus dans une seule famille ; ils ont été suivis de 45 cas déclarés dans trois hôpitaux publics. Cette investigation avait pour objectifs de détailler les caractéristiques épidémiologiques de ce groupe de cas et d'identifier les facteurs de risque potentiels ainsi que les mesures de lutte à mettre en place afin d'empêcher la survenue de nouveaux cas de MERS. Nous avons consulté les dossiers médicaux de l'ensemble des cas confirmés, avons interrogé les membres des foyers touchés et passé en revue les interventions entreprises par les autorités sanitaires. Tous les cas étaient reliés entre eux. Le cas indicateur était un homme de 62 ans ayant eu des contacts étroits avec des dromadaires ; trois des sept membres infectés de la famille et 18 patients hospitalisés sont décédés [taux de létalité : 40,4%]. La période d'incubation médiane était d'environ 6 jours. Le groupe de cas était vraisemblablement dû à une forte exposition au MERS, associée à un diagnostic tardif, une communication sur les risques inappropriée et une mauvaise observance des mesures de prévention et de lutte contre les infections par les personnels de santé de l'hôpital et les visiteurs

Strategic approach to control of viral haemorrhagic fever outbreaks in the Eastern Mediterranean Region: report from a regional consultation.

The viral haemorrhagic fevers (VHF) are a growing public health threat in the Eastern Mediterranean Region. Nearly all of them are of zoonotic origin. VHF often cause outbreaks with high fatalities and, except for yellow fever, currently there are no specific treatment or vaccination options available. In response to this growing threat, the Regional Office for the Eastern Mediterranean of the World Health Organization convened a technical consultation in Tehran on 27-30 November 2011 to review the current gaps in prevention and control of VHF outbreaks in the Region. The meeting recommended a number of strategic public health approaches for prevention and control of VHF outbreaks through synergizing effective collaboration between the human and animal health sectors on areas that involve better preparedness, early detection and rapid response. Implementation of these approaches would require working together with vision, commitment and a sense of purpose involving partnerships and cooperation from all relevant sectors.

Strategic approach to control of viral haemorrhagic fever outbreaks in the Eastern Mediterranean Region: report from a regional consultation

The viral haemorrhagic fevers [VHF] are a growing public health threat in the Eastern Mediterranean Region. Nearly all of them are of zoonotic origin. VHF often cause outbreaks with high fatalities and, except for yellow fever, currently there are no specific treatment or vaccination options available. In response to this growing threat, the Regional Office for the Eastern Mediterranean of the World Health Organization convened a technical consultation in Tehran on 27-30 November 2011 to review the current gaps in prevention and control of VHF outbreaks in the Region. The meeting recommended a number of strategic public health approaches for prevention and control of VHF outbreaks through synergizing effective collaboration between the human and animal health sectors on areas that involve better preparedness, early detection and rapid response. Implementation of these approaches would require working together with vision, commitment and a sense of purpose involving partnerships and cooperation from all relevant sectors

Clinical management guidelines for pandemic (H1N1) 2009 virus infection in the Eastern Mediterranean Region: technical basis and overview.

During the spring of 2009, a novel influenza A (H1N1) virus of swine origin caused human infection and acute respiratory illness in Mexico. After initially spreading in North America, the virus spread globally resulting in the first influenza pandemic since 1968. While the majority of illnesses caused by pandemic (H1N1) 2009 were mild and self-limiting, severe complications, including fatalities, were also reported. In view of the increasing number of laboratory-confirmed cases and deaths from pandemic (H1N1) 2009 in the Eastern Mediterranean Region of the World Health Organization, the Regional Office convened a consultation meeting of experts involved in the clinical management of patients infected with pandemic (H1N1) 2009 virus. The consultation resulted in developing an interim guidance and algorithm for clinical management of pandemic (H1N1) 2009 virus infection in health-care settings. This paper describes the process, the technical basis and the components of this interim guidance.

Clinical management guidelines for pandemic [H1 N1] 2009 virus infection in the Eastern Mediterranean Region: technical basis and overview

During the spring of 2009, a novel influenza a [H1N1] virus of swine origin caused human infection and acute respiratory illness in Mexico. After initially spreading in North America, the virus spread globally resulting in the first influenza pandemic since 1968. While the majority of illnesses caused by pandemic [HINT] 2009 were mild and self-limiting, severe complications, including fatalities, were also reported. In view of the increasing number of laboratory-confirmed cases and deaths from pandemic [HINT] 2009 in the Eastern Mediterranean Region of the World Health Organization, the Regional office convened a consultation meeting of experts involved in the clinical management of patients infected with pandemic [H1N1] 2009 virus. The consultation resulted in developing an interim guidance and algorithm for clinical management of pandemic [HINT] 2009 virus infection in health-care settings. This paper describes the process, the technical basis and the components of this interim guidance

Establishment of public health security in Saudi Arabia for the 2009 Hajj in response to pandemic influenza A H1N1.

Mass gatherings of people challenge public health capacities at host locations and the visitors' places of origin. Hajj--the yearly pilgrimage by Muslims to Saudi Arabia--is one of the largest, most culturally and geographically diverse mass gatherings in the world. With the 2009 pandemic influenza A H1N1 and upcoming Hajj, the Saudi Arabian Ministry of Health (MoH) convened a preparedness consultation in June, 2009. Consultants from global public health agencies met in their official capacities with their Saudi Arabian counterparts. The MoH aimed to pool and share public health knowledge about mass gatherings, and review the country's preparedness plans, focusing on the prevention and control of pandemic influenza. This process resulted in several practical recommendations, many to be put into practice before the start of Hajj and the rest during Hajj. These preparedness plans should ensure the optimum provision of health services for pilgrims to Saudi Arabia, and minimum disease transmission on their return home. Review of the implementation of these recommendations and their effect will not only inform future mass gatherings in Saudi Arabia, but will also strengthen preparedness efforts in other settings.

Determinants of case fatality rates of meningococcal disease during outbreaks in Makkah, Saudi Arabia, 1987-97.

We studied case-fatality rates (CFRs) among cases of meningococcal disease (MCD) admitted to Makkah (Saudi Arabia) hospitals during the period 1988-97. Of 483 cases, 431 (89.2%) were due to strains of serogroup A, 31 (6.4%) to serogroup W135, 16 (3.3%) to serogroup C, and 5 (10%) to serogroup B. Eighty-one patients died (case fatality rate (CFR)) 16.8%, 95% CI 13.5%, 20.4%). The CFR in infections due to serogroup A strains was 14.8%, and for other serogroups it was 32.7% (95% CI 20.3%, 47.1%). The CFR of MCD due to N. meningitidis serogroup A increased steadily with age (P<0.05). Seeking first medical help at a foreign Hajj medical mission and being treated in a non-specialized hospital were associated with a higher case fatality rate.

Intrafamilial person-to-person spread of bacillary dysentery due to Shigella dysenteriae in southwestern Saudi Arabia.

OBJECTIVE: To identify the factors that influence transmission of bacillary dysentry (BD) within families during a propagated outbreak of bacillary dysentery. DESIGN: A retrospective cohort study. SETTING: Eighteen neighbouring villages in rural Gizan, southwestern Saudi Arabia. SUBJECTS: Two hundred and thirty three cases of BD were identified among seventy nine families. RESULTS: Secondary cases of BD occurred in 57 of 79 families with a primary case of BD. The secondary attack rate per cent (AR%) within families ranged between 7.7% and 80%. Age of primary cases did not correlate with degree of secondary AR% in exposed families (p > 0.04; p > 0.05); however, within households, the age of the first secondary cases (median = two years) was usually less than the age of the primary case (median = six years). Children under five years of age constituted 43% of secondary cases. The median interval between successive cases within a house ranged from three and seven days. Two hundred and twenty cases (94.4%) gave history of close contact within another case of BD. Cases of BD were exposed to close relatives with BD (79.1%), neighbours (11.4%), and friends (9.5%). Risk factors influencing the spread of BD within families included two rooms or fewer per house (OR = 4.3, 9.5% CI 1.3-14.3), family size of five or more (p = 0.012, two-tailed Fisher's exact test), and presence of more than two persons per room (OR = 11.2, 95% CI 3.1-42.4). CONCLUSION: Person-to-person secondary transmission can amplify the spread of bacillary dysentery within households and neighbouring villages. Crowding was a risk factor that amplified transmission of BD within families.

Evaluation of National Immunization Days in high risk area of Saudi Arabia.

Full text is available as a scanned copy of the original print version.

Utilization of Primary Health Care Services during Hajj.

Full text is available as a scanned copy of the original print version.

Profile of diabetic Omani pilgrims to Mecca.

The annual pilgrimage to Makkah (Mecca), Hajj, is a very stressful endeavour and requires strenuous physical effort, especially for the diabetic, the elderly and persons with other chronic illnesses. To identify the complications and to assess the needs of the Omani diabetics during Hajj (DOH), a special diabetes clinic was established in the camping site of Omani pilgrims (Hajjees) in Mina, where all Omani Hajjees convene for three days. The socio-demographic characteristics, the diabetes profile and the knowledge about complications of diabetes of all DOH were ascertained; their random blood sugar (RBS) was tested. Of 10,800 Omani who performed the Hajj in 1996, the 169 Hajjees with diabetes mellitus (prevalence rate 16 per 1000) included four per cent insulin dependent (IDDM), seven per cent on dietary control, and 89% on oral hypoglycaemic agents. Almost all DOH (98%) were medically examined before their departure for Hajj. All Hajjees with IDDM and 96% on oral hypoglycaemic agents brought their medicines with them. During the Hajj period, 2.4% of DOH had RBS < 75 mg/dl, 14% 75-110 mg/dl, and 49% were hyperglycaemic (RBS > 200 mg/dL). About half of the DOH (48%) knew the clinical presentation of hyperglycaemia, a fourth (24%) about symptoms of hypoglycaemia. Only 9.5% were trained to test themselves for blood sugar. The median age of DOH was 54 years (inter-quartile range 50-62). Some 7.5% females and 4.9% of males were obese (body mass index > 30). Forty seven (28%) of the DOH had other coronary heart diseases, hypertension or both. DOH moved between Holy places (four journeys; 5-15 km long) on foot (40%), by car or bus (31%), or both (29%). All DOH except one were not wearing protective shoes, 70% did not have identification wrist bands that show their diabetic status and regimen for treatment. Four per cent lost their way during Hajj, four per cent suffered from heat exhaustion, three per cent had cut wounds, 1.2% had pneumonia, and two per cent went into coma. There is a need for a special health education programme and for special services for the diabetics during Hajj. Hajjees should learn about symptoms and signs of hypoglycaemia, were protective shoes and identifying wrist bands. Specialised services for the diabetics would alleviate a lot of the stress during Hajj among the diabetics.

An outbreak of food poisoning associated with restaurant-made mayonnaise in Abha, Saudi Arabia.

In May 1996, an outbreak of gastroenteritis occurred among customers who bought dinner from a restaurant that specialised in fried chicken in Abha city, south-west Saudi Arabia. The median incubation period was 10 hours (range: 3 to 27 hours). Of the 10 food items served, only mayonnaise (RR 2.52; 95% CI 1.71-3.73) and minced garlic (RR 1.20; 95% CI 1.02-1.41) were associated with cases. Salmonella enterica was isolated from 124 (84%) of the 159 persons with symptoms of food poisoning, and 91 (73%) were serogroup Enteritidis, phage type B 14. Mayonnaise was prepared in the restaurant using a regular blender. Minced garlic was prepared with the same blender immediately after making the mayonnaise. Unsafe storage of the mayonnaise at room temperature for a median of 6 hours could have resulted in overgrowth of bacteria and a high infective dose of bacteria per serving.

Epidemiological investigation of an outbreak of meningococcal meningitis in Makkah (Mecca), Saudi Arabia, 1992.

During March and April of 1992, the health surveillance system began detecting increasing numbers of cases of meningococcal disease (MCD) in the Islamic holy city of Makkah (Mecca). We identified 102 bacteriologically confirmed cases (CC) and 80 suspected cases (SC) of MCD. Neisseria meningitidis was identified as Group A, III-1 clone. The ratio of male:female cases was 2.9:1. All age groups of males were affected. There was only one case among women aged 10-30; 50% of the adult female cases were 55 or older. The case-fatality ratio (CFR) was 14.7% among CC. Pakistanis, who comprised about one-third of the CC, had a CFR of 26.7%. Fifty-nine percent of CC were religious visitors. CC in residents were most common in persons living near the Holy Mosque (Haram), where the carriage rate reached 86%. A mass vaccination program against MCD was instituted, using AC bivalent meningococcal vaccine (MCV). An abrupt drop, from a mean of 15 CC per week to 2 CC per week (only in visitors), coincided with vaccinating 600,000 persons over 2 weeks. Makkah residents who had been vaccinated against MCD were less likely to have contracted MCD (OR = 0.17, 95% CI: 0.06-0.50). MCV was of no significant protective value if it had been administered 5 years before the outbreak. The main reason for not being vaccinated as stated by both cases (71%) and controls (45%) was not knowing about the disease. The age and sex differences probably relate to differences in exposures to crowded conditions. Health education should illuminate the seriousness of the disease and the importance of vaccination.

An outbreak of typhoid fever among children who attended a potluck dinner at Al-Mudhnab, Saudi Arabia.

In June 1992, 19 cases of typhoid fever were reported from the town of Al-Mudhnab town (population 10,000) in the Qassim region of central Saudi Arabia. Ten of the cases were females (53%), and these were clustered by onset in a 15-day period. Cases in boys followed the girls and were more dispersed over time. Cases included 14 school-age children, four pre-school children, and the wife of a girls' school bus driver. The attack rates (AR) did not differ between boys' and girls' schools and ranged from 5.5 to 15.87 per 1,000 in six different schools. All patients except one lived within two blocks in one quarter of the town. Typhoid fever was associated with attending a school potluck dinner (OR = 5.31; 95% CI 1.02, 28.85) or eating food prepared for that dinner (OR = 6.95; 95%; CI 1.40, 36.61). Cake with cream topping from the dinner was kept overnight at room temperature and served to girls on the bus the next day. The OR of eating leftover cake on the school bus and becoming ill was 11.04 (95%; CI 1.59, 95.27). The localization of this outbreak by time and place and by the age groups affected, supports the conclusion that the outbreak was foodborne. The most likely food was cream topping on the cake. Lessons on proper food handling and storage should be included in home economics classes.

Typhoid fever from water desalinized using reverse osmosis.

In May 1992, 81 bacteriologically confirmed cases of typhoid fever (TF) were identified in all districts of Tabuk City in northwestern Saudi Arabia. Attack rates (AR) in residential districts ranged from 0.9-10.3 per 10,000. Confirmed cases included 9 workers in the city's referral hospital, King Khalid Hospital (AR 140/10,000), 2 in families of medical staff, 57 in the community (AR 4.4/10,000) and 13 in a local military cantonment (AR 0.8/10,000). The outbreak began with the onset of TF in the three areas within 5 days, continued for 7 weeks, and ended 2 weeks after chlorination began. Among water sources, the odds ratio (OR) was highest (2.6; 95% confidence interval [CI] 1.25-5.39) for water purchased from reverse osmosis (RO) plants, especially RO plants supplied by one well (ASUW) (OR = 7.05; 95% CI 2.51-20.7). The aquifer for ASUW lay partially beneath a depression where city sewage collected. Unchlorinated water samples from ASUW 1 month after the outbreak ended yielded coliforms. ASUW probably became contaminated with Salmonella typhi when KKH demand overtaxed the aquifer and drew in surface water. Membranes in RO plants using this unchlorinated well water could then become fouled with S. typhi. RO plants, which are common throughout Saudi Arabia, need close monitoring. Water for RO must be prechlorinated to prevent microbiologic fouling of the membranes.

Plasma retinol-binding protein levels of children under five years of age in a displaced Sudanese community.

Blood samples (100-160 microliters) were obtained from 1360 children by a finger prick in heparinized collection tubes, and an LC-Partigen retinol-binding protein (RBP) kit was used for quantification of RBP in the plasma. Only three boys and two girls had plasma RBP that was equal to or more than 3.0 mg/dL, a recommended cut-off point for normal values. The mean +/- SD) plasma RBP levels were at 1.150 +/- 0.613 mg/dL for boys (N = 689) and 1.233 +/- 0.572 mg/dL for girls (N = 671). The difference between boys and girls was statistically significant (p < 0.001). None of the children included in this study had eye signs of vitamin A deficiency. Two hundred eighty-two children (19.6%) received vitamin A supplements (200,000 IU) before the beginning of the study. The mean +/- SD for plasma RBP for children who received vitamin A supplement were 1.159 +/- .762 mg/dL for boys and 1.151 +/- 0.470 mg/dL for girls. The observed discrepancy between the biochemical and clinical manifestations of vitamin A deficiency was discussed.

Infant-feeding practices in urban and rural communities of the Sudan.

Infant-feeding and weaning practices were investigated in a multistage randomly selected sample of 1,039 Sudanese mothers who represented six of the nine States of the Sudan. The majority (77.9%) believed that breast milk was best for their babies, emphasizing the previously reported high breast-feeding rate in Sudanese mothers. Food supplementation started by 6 months in 82.5% mainly in urban middle and high classes (UMC and UHC) compared to urban poor class (UPC) and the rural group (RG; p < 0.001). A mixture of food items was used for supplementation by 62.1% of the study group, whereas giving one food item was significantly more practised in RG (54.9%) compared to others (p < 0.001). Household food was introduced by 6 months in 35.4%. Weaning started between 6 and 12 months in 27.1% and thereafter in 64.9%. A greater proportion of rural mothers (36.5%) weaned their babies after the age of 18 months (p < 0.001). About half the children (52.8%) were weaned abruptly, mainly among UPC and RG. The first food item of choice for weaning was fresh goat's or cow's milk (77.6%), followed by powdered or formula milk (16.1%). The commonest second preferred food was a starch gruel (39.1%) made either of rice (24.5%) or fermented sorghum.

PIP: In six of the nine states of the Sudan, a random multistage cluster sampling technique was used to select 1039 mothers in the towns of Shandi, Port Sudan, El Fashir, Kosti, El Hasahisa, Omdurman, the village of Ellirri, and villages near Shandi, Sinkat, and Abu Hamad. Medical students from the selected areas interviewed the mothers. The study aimed to examine infant feeding and weaning practices. 77.4% of the mothers considered breast milk to be best for their baby, reflecting the high breast feeding rate (92% at 6 months) reported previously. The foods identified as second-best were local cereals (e.g., fermented sorghum gruel) (36.9%), fresh goat's or cow's milk (22.5%), bananas and oranges (11.3%), and formula milk (7.7%). Only 1% of newborns received food supplements. 82.5% of mothers supplemented breast milk with other foods by age 6 months. The urban high and middle classes were more likely to practice food supplementation at 6 months than the urban poor and the rural groups (90.3% and 89.7% vs. 79.3% and 74.1%, respectively; p 0.001). 62.1% of all mothers supplemented breast milk with a mixture of foods. Rural mothers were more likely to supplement with only one food item than urban mothers (54.9% vs. 28.3-30.6%; p 0.001). 35.4% and 90.7% of mothers introduced household foods at 6 and 9 months, respectively. 27.1% of mothers began weaning between 6 and 12 months. 64.9% of mothers began weaning after 12 months. A significant percentage of rural mothers (36.5%) began weaning after 18 months (p 0.001). 52.8% of mothers weaned their children abruptly, especially rural women and the urban poor. The most preferred first weaning foods were fresh milk (77.6%) and powdered or formula milk (16.1%). The most preferred second weaning foods were starch gruel made of fermented sorghum or rice (39.1%) and powdered or formula milk (19.1%).

Attitudes and practices of breast-feeding in Sudanese urban and rural communities.

The study was designed to investigate attitudes and practices of breast-feeding in a representative sample of 1039 Sudanese mothers and document corresponding influencing factors in urban and rural communities in six states. Urban mothers were represented by three (high, middle and poor) socioeconomic classes. Almost all mothers (99.9%) initiated breast-feeding, mostly (83.2%) on the first day between 1-5 hours following delivery. Delay of 6 or more hours was practiced mainly by rural mothers (p < 0.001). The breast-feeding rate was 92.0% at 7 months and 65.0% at one year. Four per cent still breast-fed at 2 years. Urbanization affected frequency of breast-feeding adversely; whereas the presence of sore or retracted nipple had a negative effect on its duration (p < 0.02 and < 0.01, respectively). The majority (89.2%) thought that a new pregnancy contraindicated the continuation of breast-feeding and 67.1% reduced or stopped it if the baby had diarrhoea. On the whole, despite the rapid demographic shifts which the Sudan had witnessed recently, positive attitudes to breast-feeding and its duration were still holding. However, there was a tendency towards shorter duration of breast-feeding in urban affluent mothers in comparison to others.

PIP: The study was designed to investigate attitudes and practices of breast-feeding in a representative sample of 1039 Sudanese mothers and document corresponding influencing factors in urban and rural communities in 6 states. Urban mothers were represented by 3 (high, middle, and poor) socioeconomic classes. Almost all mothers (99.9%) initiated breast-feeding, mostly (83.2%) on the first day between 1 to 5 hours following delivery. Delay of 6 or more hours was practiced mainly by rural mothers (p 0.001). The breast-feeding rate was 92.0% at 7 months and 65.0% at 1 year. 4% still breast-fed at 2 years. Urbanization affected frequency of breast-feeding adversely; whereas the presence of sore or retracted nipple had a negative effect on its duration (p 0.02 and 0.01, respectively). The majority (89.2%) thought that a new pregnancy contraindicated the continuation of breast-feeding and 67.1% reduced or stopped it if the baby had diarrhea. On the whole, despite the rapid demographic shifts which the Sudan had witnessed recently, positive attitudes to breast-feeding and its duration were still holding. However, there was a tendency towards shorter duration of breast-feeding in urban affluent mothers in comparison to others. (author's