Nosocomial amplification of MERS-coronavirus in South Korea, 2015

BACKGROUND: Nosocomial amplification resulted in nearly 200 cases of Middle East respiratory syndrome (MERS) during the 2015 South Korean MERS-coronavirus outbreak. It remains unclear whether certain types of cases were more likely to cause secondary infections than others, and if so, why. METHODS: Publicly available demographic and transmission network data for all cases were collected from the Ministry of Health and Welfare. Statistical analyses were conducted to determine the relationship between demographic characteristics and the likelihood of human-to-human transmission. Findings from the statistical analyses were used to inform a hypothesis-directed literature review, through which mechanistic explanations for nosocomial amplification were developed. RESULTS: Cases that failed to recover from MERS were more likely to cause secondary infections than those that did. Increased probability of direct, human-to-human transmission due to clinical manifestations associated with death, as well as indirect transmission via environmental contamination (e.g., fomites and indoor ventilation systems), may serve as mechanistic explanations for nosocomial amplification of MERS-coronavirus in South Korea. CONCLUSIONS: In addition to closely monitoring contacts of MERS cases that fail to recover during future nosocomial outbreaks, potential fomites with which they may have had contact should be sanitized. Furthermore, indoor ventilation systems that minimize recirculation of pathogen-bearing droplets should be implemented whenever possible.