The patient started feeling ill as he sat on a packed flight from Jeddah to London. Things didn’t get any better after he boarded another flight to Boston, or a third flight to Atlanta, or even as he took one last miserable leg to Orlando.
If he’d been watching the news, he should have known it was at least possible that he had MERS, the mysterious new Middle East respiratory virus. It’s been spreading in Saudi Arabia and has infected more than 570 people globally, killing 171 of them. The biggest risk factor is being a health care worker, like the patient.
Still, he boarded multiple flights and came into an Orlando hospital without warning he had respiratory symptoms and had come from Saudi Arabia. He spent hours in a public emergency room, potentially exposing other patients to his infection.
Showing up in an emergency department without warning results in just what has happened in Orlando — 20 health care workers in quarantine for two weeks. Patients who were in the waiting room are being tracked down just to be sure they know what to do if they develop cough or fever.
Two workers who helped care for him did develop respiratory symptoms, causing a great deal of concern, but they have tested negative for MERS.
The case shows just how important it is to control infections at hospitals.
"We feel like getting infection control is issue number one," the World Health Organization's Dr. Keiji Fukuda told a news conference on Wednesday.
“If you get sick within 14 days of being in the Arabian Peninsula, call a doctor and tell the doctor where you traveled."
There’s little excuse for not knowing about the possibility of infection now — the U.S. Centers for Disease Control and Prevention is posting signs at major airports, warning of the symptoms. “If you get sick within 14 days of being in the Arabian Peninsula, call a doctor and tell the doctor where you traveled,” the signs advise.
And now the World Health Organization, has too, even as it stopped short of declaring MERS a global health emergency.
CDC has repeated this advice at regular intervals, most recently after an Indiana man who’d been working in a Saudi hospital became the first U.S. MERS patient. He doesn’t remember having treated anyone with MERS but did work at a hospital in Riyadh with MERS cases.
The second patient also worked at a hospital where MERS was being treated, this one in Jeddah, his doctors said.
The 44-year-old health care worker laid low with relatives in the Orlando area for a few days, finally feeling bad enough to go to the emergency room at Dr. P. Phillips Hospital. He was admitted May 9, and tests confirmed on Monday he was the second patient to show up in the United States with MERS.
But the professionals who treated him on Friday night already suspected he might have MERS. Anyone coming from the Arabian peninsula with respiratory symptoms should be considered a potential case, CDC says. That means extreme hygiene measures, including an isolation room.
"I have to wear a special mask called an N-95 (respirator). I have to wear a gown and gloves. Once we get out of the room we dispose of everything," said Dr. Antonio Crespo, infectious disease specialist and chief quality officer for the P. Phillips Hospital.
It’s a pain to do this, says Dr. Tim Lahey, associate professor of microbiology and immunology at Dartmouth’s medical school. “It’s hard,” he said. Even just washing hands between every patient —something every health professional should so with every single patient, MERS or not — is a nuisance.
“We should admit that not only is it easy to forget about, but it’s also inconvenient. It takes time,” he said.
“Previously it had been completely socially respectable and even expected for health care workers to come to work while sick.”
And doctors, nurses and other health care workers can be cavalier about germs.
"There is a lot of good guidance," Fukuda said. "The most difficult thing about infection prevention and control is how to get them implemented on a general basis. This is true in every country in the world. It is simply a difficult thing to get people to do consistently."
For instance, doctors, nurses and technicians may wear gloves but then not not change them between every patient. Or they may wear a mask,but not change it between patients.
"One of the easiest things you can do is wash your hands between patients," Fukuda said. "Study after study has shown that something as simple as that is done inconsistently and that it doesn’t matter what country."
In the United States, federal health officials have been pushing for a change, as have groups dedicated to infection control.
“The culture in healthcare is changing as we speak,” said Lahey. “Previously it had been completely socially respectable and even expected for health care workers to come to work while sick.”
It’s partly dedication, he said. “We realize now that it is not healthy. It is not healthy for us and it is not healthy for our patients.”
And with MERS, it can be a life-or-death matter. Twenty percent of the more than 570 people infected with MERS have been healthcare workers. It’s because of the prolonged, close contact with patients.
Treating someone with a severe respiratory illness is messy, as doctors found out with SARS, or severe acute respiratory syndrome, the viral cousin of MERS that sickened more than 8,000 people and killed more than 770 before it was stopped in 2004.
“If you are a caregiver or a nurse and you are suctioning them and the patient is coughing…these are the kind of people in Toronto with SARS who tended to get the infection,” said Dr. Ken Michaels of the Florida Department of Health in Orange County. “I would imagine in Saudi Arabia that would be the experience." Thus the gloves, gowns and goggles on anyone treating such a patient, as viruses can enter the nose, mouth or eyes.
SARS turned out to be highly infectious. A single man infected several other people who stayed in the same hotel as he did in Hong Kong.
MERS doesn’t seem to be that bad, but the CDC and other experts say it’s not worth taking the risk.
"We don’t really know exactly how MERS is transmitted and we don’t really know what the full spectrum of disease is,” said Lahey.
Nonetheless, the pattern of MERS so far suggests there is very little danger to the general public or even to people who sat next to the patient on an airplane or even in hospital waiting rooms. “I believe the risk is negligible to the people in the waiting rooms,” said Michaels.