Nawfal Aljerian

The impact of crowd control measures on the occurrence of stampedes during Mass Gatherings: The Hajj experience

BACKGROUND Mass gatherings present enormous challenges for emergency preparedness. Planners must anticipate and prepare for communicable and non-communicable disease outbreaks, illnesses, and injuries to participants, crowd control, and disaster responses to unforeseen natural or man-made threats. The Hajj, the largest annually recurring mass gathering event on earth. It attracts about 3 million pilgrims from over 180 countries who assemble in Mecca over a 1-week period. METHODS A literature review was conducted using Medline and OVID, while searching for published data concerning human stampedes and crowd control measures implemented to prevent human stampedes. The review was further extended to include media reports and published numbers and reports about Hajj from the Saudi Arabian government, in both the English and Arabic languages. RESULTS Because millions of pilgrims undertake their religious ritual within strict constraints in term of space and time; this rigour and strictness have led to a series of large crowd disasters over several years, thus putting pressure on the authorities. In the past few years, the government of Saudi Arabia have put an enormous effort to solve this difficulty using state of the art innovative scientific means. The use of crowd simulation models, assessment of the best ways of grouping and scheduling pilgrims, crowd management and control engineering technologies, luggage management, video monitoring, and changes in the construction of the transport system for the event. CONCLUSIONS A large gathering such as the Hajj still holds an increasing risk for future disasters. International collaboration and continued vigilance in planning efforts remains an integral part of these annual preparations. The development of educational campaigns for pilgrims regarding the possible dangers is also crucial. Lessons gleaned from experiences at the Hajj may influence planning for mass gatherings of any kind, worldwide.

Unusual presentation of Middle East respiratory syndrome coronavirus leading to a large outbreak in Riyadh during 2017

HighlightsHCF outbreaks of MERS‐CoV continue to happen but with lower frequency and size.Outbreaks are being ignited with unusual challenging cases that are difficult to pick up in emergency room (CRF and Chronic Heart Disease).Superspreading events are multifactorial with host, virus and environment playing key role.Point of care testing is the highest priority in limiting such cases in the future. Background: The hallmark of Middle East respiratory syndrome coronavirus (MERS‐CoV) disease is the ability to cause major health care‐associated nosocomial outbreaks with superspreading events leading to massive numbers of cases and excessive morbidity and mortality. In this report, we describe a patient who presented with acute renal failure requiring hemodialysis and became a MERS‐CoV superspreader, igniting a recent multihospital outbreak in Riyadh. Material and Results: Between May 31 and June 15, 2017, 44 cases of MERS‐CoV infection were reported from 3 simultaneous clusters from 3 health care facilities in Riyadh, Saudi Arabia, including 11 fatal cases. Out of the total reported cases, 29 cases were reported from King Saud Medical City. The cluster at King Saud Medical City was ignited by a single superspreader patient who presented with acute renal failure. After 14 hours in the open area of the emergency department and 2 hemodialysis sessions he was diagnosed with MERS‐CoV. One hundred twenty contacts who had direct unprotected exposure were screened. Among those contacts, 9 out of 107 health care workers (5 nurses, 3 physicians, and 1 paramedic) and 7 out of 13 patients tested positive for MERS‐CoV. Conclusions: This hospital outbreak demonstrated the difficulties in diagnosing pneumonia in patients with renal and cardiac failure, which leads to delayed suspicion of MERS‐CoV and hence delay in applying the proper infection control procedures. In MERS‐CoV endemic countries there is an urgent need for developing rapid point‐of‐care testing that would assist emergency department staff in triaging suspected cases of MERS‐CoV to ensure timely isolation and management of their primary illness and prevent major MERS‐CoV outbreaks.

Objection to chronic disease based restrictions during the Hajj

1 Strnad V, Ott OJ, Hildebrandt G. 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet 2015; 387: 229–38. 2 Haviland JS, Bliss JM, Bentzen SM, et al. The TARGIT-A trial: understanding noninferiority and survival analysis. Int J Radiat Oncol Biol Phys 2015; 92: 954–55. 3 Cuzick J. Radiotherapy for breast cancer, the TARGIT-A trial. Lancet 2014; 383: 1716. 4 Hepel J, Wazer DE. A fl awed study should not defi ne a new standard of care. Int J Radiat Oncol Biol Phys 2015; 91: 255–57. 5 Yarnold J, Bentzen SM, Brunt AM, et al. Re: Start of cheaper technique for breast cancer is delayed in UK despite adoption elsewhere. BMJ 2015; 350: h2874. 6 Coles CE, Yarnold JR. Accelerated partial breast irradiation: the new standard? Lancet 2016; 387: 201–02. 7 Haviland JS, Owen JR, Dewar JA, et al. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol 2013; 14: 1086–94. 8 Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med 2010; 362: 513–20.

Paramedics beliefs and attitudes towards pre-hospital thrombolysis

Background: Myocardial infarction is the third leading cause of death in the developing countries. Thrombolysis as a reperfusion therapy is shown to have a great role in decreasing mortality. The efficacy of thrombolytic therapy lies in its ability to reduce the duration of occlusion by early administration. Many of the studies have supported pre-hospital thrombolysis (PHT) therapy and proven that it is beneficial in acute myocardial infarction (AMI) patients. Methodology: Questionnaires adopted from studies of Humphrey et al., were distributed to paramedics in Saudi Red Crescent Authority and Emergency Medical Services Departments at King Abdulaziz Medical City, King Fahad Medical City, Prince Sultan Medical Military City and Security Forces Hospital in Riyadh. A total of 7 questions were about the knowledge of risk and benefit of PHT and 12 questions were about the beliefs and attitudes of paramedics toward PHT in AMI patients. Results: The response rate was 87%. Nearly 72% were believed to be capable of performing PHT, 87% are confident about recording 12-lead electrocardiogram in pre-hospital settings and 77% are confident in the interpretation. 94% believe that PHT will have a significant impact on pain to needle time. 77% consider PHT to be safe for use by paramedics. 66% preferred on-line medical direction or telemedicine linked with the supervision of a physician. Regarding the knowledge part, majority gave a correct answer, but the major concern was that 43% of the paramedics overestimated direct relation of bleeding to thrombolysis therapy. Conclusion: Majority of paramedics in Riyadh support the principle of PHT in patients with AMI via online medical direction. They believe that they are confident in their ability to administer PHT despite the concern of authorities on their level of training, the related risks and medico-legal issues. Nevertheless, since the total duration of PHT course for paramedics is just 2 days, we consider that the procedure should be performed under expert supervision until they achieve expertise.

Middle East Respiratory Syndrome: Global Outbreak Data Analysis

Background: The Middle East Respiratory Syndrome coronavirus (MERS-CoV) is a new human disease initially reported from the Arabian Peninsula in September 2012. Since then, the disease has spread worldwide. We present the available demographic and epidemiological data reported by the World Health Organization (WHO). Methods: We abstracted and analyzed all disease outbreak news archives from WHO about MERS-CoV between September 23, 2012 and December 4, 2015. Results: One thousand six cases of Middle East Respiratory Syndrome (MERS) were identified, with an average age of 52.7 years and where males comprised 68.1% of the cases. Comorbidities and healthcare workers reported in 47.1% and 15.5% of cases respectively. History of camel contact was reported in 9.8% of cases and contact with a laboratory confirmed MERS-CoV case was reported in 21.6% of cases. The overall mean (SD) from symptoms onset to date of laboratory confirmation was 5.2 days (4.2 days), CI 95% [4.9-5.6]. Conclusion: Our analyses demonstrated males are predominately affected by this disease. Observing the period from date of symptoms onset to date of laboratory confirmation was shorter among female patients and patients without comorbidities. In addition, it was significantly shorter in 2015 compared with 2014. Further analysis of an available MERS-CoV database could provide better understanding and guidance for future research activities.