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.

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.

Middle East Respiratory Syndrome Coronavirus Infection Dynamics and Antibody Responses among Clinically Diverse Patients, Saudi Arabia.

Middle East respiratory syndrome coronavirus (MERS-CoV) shedding and antibody responses are not fully understood, particularly in relation to underlying medical conditions, clinical manifestations, and mortality. We enrolled MERS-CoV-positive patients at a hospital in Saudi Arabia and periodically collected specimens from multiple sites for real-time reverse transcription PCR and serologic testing. We conducted interviews and chart abstractions to collect clinical, epidemiologic, and laboratory information. We found that diabetes mellitus among survivors was associated with prolonged MERS-CoV RNA detection in the respiratory tract. Among case-patients who died, development of robust neutralizing serum antibody responses during the second and third week of illness was not sufficient for patient recovery or virus clearance. Fever and cough among mildly ill patients typically aligned with RNA detection in the upper respiratory tract; RNA levels peaked during the first week of illness. These findings should be considered in the development of infection control policies, vaccines, and antibody therapeutics.

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.

Factors associated with smoking initiation among Saudi male adolescents: A longitudinal study.

INTRODUCTION: Knowing country-specific predictors of smoking behaviour for adolescents is crucial for successful smoking prevention programs. This study aims to assess demographic and socio-cognitive variables related to smoking initiation among Saudi male adolescents. METHODS: Longitudinal data were collected at T1 (baseline) and at T2 (followup at 6 months) using a self-administered questionnaire. We assessed smoking behaviour and related demographic variables and socio-cognitive variables. Chi-squared tests and independent-samples t-tests were used to identify differences in baseline characteristics between smokers and non-smokers at T1. Furthermore, non-smokers at T1 were included in logistic regression analyses to examine the predictors of smoking initiation between T1 and T2. RESULTS: At T1, the non-smokers who were included in further analysis were 523 (84.9%) of whom 48 (9.2%) had initiated smoking at T2. They differed significantly from non-initiators, including having a more positive attitude towards smoking, reporting more social norms, modelling and pressure to smoke, having a lower self-efficacy to refrain from smoking and higher intention to smoke in the future (all p<0.001). The regression analysis revealed that: adolescents with disrupted-families, being of low academic achievement, with relatively high monthly-income families, having more smoking-peers, high-perceived pressure to smoke from parents (p=0.002) and teachers (p=0.001), have smoking supportive-norms of parents and having high intention to smoke in the future (p<0.001) were at higher risk of being smokers. CONCLUSIONS: Findings suggest that health-promoting programs should address strengthening of self-efficacy and enhancing refusal skills against modelling of peers, pressure and norms of parents.

Infectious MERS-CoV Isolated From a Mildly Ill Patient, Saudi Arabia.

Middle East respiratory syndrome coronavirus (MERS-CoV) is associated with a wide range of clinical presentations, from asymptomatic or mildly ill to severe respiratory illness including death. We describe isolation of infectious MERS-CoV from the upper respiratory tract of a mildly ill 27-year-old female in Saudi Arabia 15 days after illness onset.

Smoking uptake among Saudi adolescents: tobacco epidemic indicators and preventive actions needed.

The aim of this cross-sectional school-based study was to assess smoking prevalence, indicators for the smoking epidemic and determinants of smoking among Saudi adolescents. The study included 695 male adolescents from 11 to 16 years of age who filled out self-report questionnaires based on the European Smoking Framework Approach questionnaire, which uses the I-Change model to assess attitude, social influence and the self-efficacy of the participants. Smokers were 275 (39.6%) adolescents. Smokers tended to receive more daily pocket money, live in more affluent families and show lower academic performance. Non-smokers were inclined to believe that smoking may help people to feel relaxed and confident, encountered less social influences to smoke than smokers, but reported low self-efficacy not to smoke when with smoker friends and when offered a cigarette. Smokers reported the lowest self-efficacy not to smoke in all situations assessed. The results suggest the smoking epidemic among male Saudi adolescents may still be in the early stages, providing ample opportunity for preventive actions aimed at halting the further progress of this epidemic. Secondly, smoking prevention programs in Saudi Arabia need to reinforce non-smoking attitudes, address how to resist pressure to smoke, and how to develop high self-efficacy towards non-smoking in various situations.

Surveillance and Testing for Middle East Respiratory Syndrome Coronavirus, Saudi Arabia, April 2015-February 2016.

Saudi Arabia has reported >80% of the Middle East respiratory syndrome coronavirus (MERS-CoV) cases worldwide. During April 2015-February 2016, Saudi Arabia identified and tested 57,363 persons (18.4/10,000 residents) with suspected MERS-CoV infection; 384 (0.7%) tested positive. Robust, extensive, and timely surveillance is critical for limiting virus transmission.

Outcome of strict implementation of infection prevention control measures during an outbreak of Middle East respiratory syndrome.

BACKGROUND: The objective of this retrospective cohort study was to assess the impact of implementation of different levels of infection prevention and control (IPC) measures during an outbreak of Middle East respiratory syndrome (MERS) in a large tertiary hospital in Saudi Arabia. The setting was an emergency room (ER) in a large tertiary hospital and included primary and secondary MERS patients. METHODS: Rapid response teams conducted repeated assessments of IPC and monitored implementation of corrective measures using a detailed structured checklist. We ascertained the epidemiologic link between patients and calculated the secondary attack rate per 10,000 patients visiting the ER (SAR/10,000) in 3 phases of the outbreak. RESULTS: In phase I, 6 primary cases gave rise to 48 secondary cases over 4 generations, including a case that resulted in 9 cases in the first generation of secondary cases and 21 cases over a chain of 4 generations. During the second and third phases, the number of secondary cases sharply dropped to 18 cases and 1 case, respectively, from a comparable number of primary cases. The SAR/10,000 dropped from 75 (95% confidence interval [CI], 55-99) in phase I to 29 (95% CI, 17-46) and 3 (95% CI, 0-17) in phases II and III, respectively. CONCLUSIONS: The study demonstrated salient evidence that proper institution of IPC measures during management of an outbreak of MERS could remarkably change the course of the outbreak.

Increase in Middle East Respiratory Syndrome-Coronavirus Cases in Saudi Arabia Linked to Hospital Outbreak With Continued Circulation of Recombinant Virus, July 1-August 31, 2015.

During July-August 2015, the number of cases of Middle East respiratory syndrome (MERS) reported from Saudi Arabia increased dramatically. We reviewed the 143 confirmed cases from this period and classified each based upon likely transmission source. We found that the surge in cases resulted predominantly (90%) from secondary transmission largely attributable to an outbreak at a single healthcare facility in Riyadh. Genome sequencing of MERS coronavirus from 6 cases demonstrated continued circulation of the recently described recombinant virus. A single unique frameshift deletion in open reading frame 5 was detected in the viral sequence from 1 case.

Effects of a randomized controlled trial to assess the six-months effects of a school based smoking prevention program in Saudi Arabia.

OBJECTIVE: To examine the efficacy of a smoking prevention program which aimed to address smoking related cognitions and smoking behavior among Saudi adolescents age 13 to 15. METHOD: A randomized controlled trial was used. Respondents in the experimental group (N=698) received five in-school sessions, while those in the control group (N=683) received no smoking prevention information (usual curriculum). Post-intervention data was collected six months after baseline. Logistic regression analysis was applied to assess effects on smoking initiation, and linear regression analysis was applied to assess changes in beliefs and analysis of covariance (ANCOVA) was used to assess intervention effects. All analyses were adjusted for the nested structure of students within schools. RESULTS: At post-intervention respondents from the experimental group reported in comparison with those from the control group a significantly more negative attitude towards smoking, stronger social norms against smoking, higher self-efficacy towards non-smoking, more action planning to remain a non-smoker, and lower intentions to smoke in the future. Smoking initiation was 3.2% in the experimental group and 8.8% in the control group (p<0.01). CONCLUSION: The prevention program reinforced non-smoking cognitions and non-smoking behavior. Therefore it is recommended to implement the program at a national level in Saudi-Arabia. Future studies are recommended to assess long term program effects and the conditions favoring national implementation of the program.

Epidemiology of a Novel Recombinant Middle East Respiratory Syndrome Coronavirus in Humans in Saudi Arabia.

BACKGROUND: Middle East respiratory syndrome coronavirus (MERS-CoV) causes severe respiratory illness in humans. Fundamental questions about circulating viruses and transmission routes remain. METHODS: We assessed routinely collected epidemiologic data for MERS-CoV cases reported in Saudi Arabia during 1 January-30 June 2015 and conducted a more detailed investigation of cases reported during February 2015. Available respiratory specimens were obtained for sequencing. RESULTS: During the study period, 216 MERS-CoV cases were reported. Full genome (n = 17) or spike gene sequences (n = 82) were obtained from 99 individuals. Most sequences (72 of 99 [73%]) formed a discrete, novel recombinant subclade (NRC-2015), which was detected in 6 regions and became predominant by June 2015. No clinical differences were noted between clades. Among 87 cases reported during February 2015, 13 had no recognized risks for secondary acquisition; 12 of these 13 also denied camel contact. Most viruses (8 of 9) from these 13 individuals belonged to NRC-2015. DISCUSSIONS: Our findings document the spread and eventual predominance of NRC-2015 in humans in Saudi Arabia during the first half of 2015. Our identification of cases without recognized risk factors but with similar virus sequences indicates the need for better understanding of risk factors for MERS-CoV transmission.

Secular trend and epidemiology of measles in the Kingdom of Saudi Arabia: 2009-2012.

PURPOSE: To determine incidence of measles and progress towards its elimination in Saudi Arabia. METHODS: A retrospective analysis of routinely collected active and passive surveillance data on measles at the Ministry of Health, Saudi Arabia. All laboratory confirmed measles from (2009-2012) were analyzed to determine measles annual incidences and distribution by age, gender, nationality, seasonality, vaccination status and spatial distribution by region. RESULTS: Measles incidence per 1,000,000 populations increased from 3.2 in 2009 to a peak of 12.8in 2011 and a slight fall to 9.9 in 2012. About 50% of cases were in children under-five years, 12% were infants and 33% were 15 years and above. Of the total, 39%were unvaccinated and16% had unknown vaccination status. Fifty-five percent of infants were not due for vaccination. Of children <5 years, 42% received vaccination. Spatial distribution is not countrywide in each of the four years but seemed to concentrate in the central and South West regions with40% in Jizan and Jeddah. CONCLUSION: High incidence of confirmed measles among unvaccinated infants requires strengthening of the immunization services. Improvement in measles case surveillance for completeness of vaccination status, vaccination of unvaccinated youths and comprehensive immunization are needed for measles elimination.