High fatality rates and associated factors in two hospital outbreaks of MERS in Daejeon, the Republic of Korea

Abstract

Objectives: To explore the epidemiological and clinical factors predictive of the case fatality rate (CFR) of Middle East respiratory syndrome-coronavirus (MERS-CoV) infection in an outbreak in Daejeon, the Republic of Korea.

Methods: We reviewed the outbreak investigation reports and medical records of 1 index case and 25 additional MERS cases in hospitals A (14 cases) and B (11 cases), and conducted an in-depth interview with the index case.

Results: The CFR in hospital B was higher than that in hospital A (63.6% vs. 28.6%, respectively). Higher MERS-CoV exposure conditions were also found in hospital B, including aggravated pneumonia in the index case and nebulizer use in a six-bed admission room. The host factors associated with high CFR were pre-existing pneumonia, smoking history, an incubation period of less than 5 days, leukocytosis, abnormal renal function at diagnosis, and respiratory symptoms such as sputum and dyspnea.

Conclusions: The conditions surrounding MERS-CoV exposure and the underlying poor pulmonary function due to a smoking history or pre-existing pneumonia may explain the high CFR in hospital B. The clinical features described above may enable prediction of the prognosis of MERS cases.

Keywords: Hospital; Korea; Middle East respiratory syndrome coronavirus; Mortality; Outbreak.

Figure 1

Location of the index case and subsequent fatal and non-fatal cases in hospitals A and B. The index case stayed in hospital A during 22–28 May 2015 and then in hospital B during 28–30 May 2015. (A) In hospital A, an engineer was presumed to be infected by the index case on a different floor; the location of his exposure is unclear. He survived. (B) In hospital B, one case (a family caregiver) was presumed to be infected by the index case in the emergency room (ER). He did not survive. Another case (a nurse) was infected by the fatal inpatient case in the isolation room of the intensive care unit (ICU). She survived.