Seroprevalence of Middle East respiratory syndrome coronavirus (MERS-CoV) in public health workers responding to a MERS outbreak in Seoul, Republic of Korea, in 2015
Identifieur interne : 000752 ( Pmc/Corpus ); précédent : 000751; suivant : 000753Seroprevalence of Middle East respiratory syndrome coronavirus (MERS-CoV) in public health workers responding to a MERS outbreak in Seoul, Republic of Korea, in 2015
Auteurs : Boyeong Ryu ; Sung-Il Cho ; Myoung-Don Oh ; Jong-Koo Lee ; Jaein Lee ; Young-Ok Hwang ; Jeong-Sun Yang ; Sung Soon Kim ; Ji Hwan BangSource :
- Western Pacific Surveillance and Response Journal : WPSAR [ 2094-7321 ] ; 2019.
Url:
DOI: 10.5365/wpsar.2018.9.3.002
PubMed: 31720054
PubMed Central: 6831962
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PMC:6831962Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Seroprevalence of Middle East respiratory syndrome coronavirus
(MERS-CoV) in public health workers responding to a MERS outbreak in Seoul,
Republic of Korea, in 2015</title><author><name sortKey="Ryu, Boyeong" sort="Ryu, Boyeong" uniqKey="Ryu B" first="Boyeong" last="Ryu">Boyeong Ryu</name><affiliation><nlm:aff id="aff1"><institution>Seoul Center for Infectious Disease Control and Prevention</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Department of Epidemiology,<institution>Seoul National University School of Public Health</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Cho, Sung Il" sort="Cho, Sung Il" uniqKey="Cho S" first="Sung-Il" last="Cho">Sung-Il Cho</name><affiliation><nlm:aff id="aff1"><institution>Seoul Center for Infectious Disease Control and Prevention</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Department of Epidemiology,<institution>Seoul National University School of Public Health</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Oh, Myoung Don" sort="Oh, Myoung Don" uniqKey="Oh M" first="Myoung-Don" last="Oh">Myoung-Don Oh</name><affiliation><nlm:aff id="aff1"><institution>Seoul Center for Infectious Disease Control and Prevention</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation><affiliation><nlm:aff id="aff3">Department of Internal Medicine,<institution>Seoul National University College of Medicine</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Lee, Jong Koo" sort="Lee, Jong Koo" uniqKey="Lee J" first="Jong-Koo" last="Lee">Jong-Koo Lee</name><affiliation><nlm:aff id="aff1"><institution>Seoul Center for Infectious Disease Control and Prevention</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation><affiliation><nlm:aff id="aff4">Department of Family Medicine,<institution>Seoul National University College of Medicine</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Lee, Jaein" sort="Lee, Jaein" uniqKey="Lee J" first="Jaein" last="Lee">Jaein Lee</name><affiliation><nlm:aff id="aff5"><institution>Seoul Metropolitan Government Research Institute of Public Health and Environment</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Hwang, Young Ok" sort="Hwang, Young Ok" uniqKey="Hwang Y" first="Young-Ok" last="Hwang">Young-Ok Hwang</name><affiliation><nlm:aff id="aff5"><institution>Seoul Metropolitan Government Research Institute of Public Health and Environment</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Yang, Jeong Sun" sort="Yang, Jeong Sun" uniqKey="Yang J" first="Jeong-Sun" last="Yang">Jeong-Sun Yang</name><affiliation><nlm:aff id="aff6">Korea Centers for Disease Control and Prevention, Cheongju,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Kim, Sung Soon" sort="Kim, Sung Soon" uniqKey="Kim S" first="Sung Soon" last="Kim">Sung Soon Kim</name><affiliation><nlm:aff id="aff6">Korea Centers for Disease Control and Prevention, Cheongju,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Bang, Ji Hwan" sort="Bang, Ji Hwan" uniqKey="Bang J" first="Ji Hwan" last="Bang">Ji Hwan Bang</name><affiliation><nlm:aff id="aff1"><institution>Seoul Center for Infectious Disease Control and Prevention</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation><affiliation><nlm:aff id="aff7">Division of Infectious Diseases,<institution>Seoul Metropolitan Government-Seoul National University Boramae Medical Center</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">31720054</idno><idno type="pmc">6831962</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831962</idno><idno type="RBID">PMC:6831962</idno><idno type="doi">10.5365/wpsar.2018.9.3.002</idno><date when="2019">2019</date><idno type="wicri:Area/Pmc/Corpus">000752</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000752</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Seroprevalence of Middle East respiratory syndrome coronavirus
(MERS-CoV) in public health workers responding to a MERS outbreak in Seoul,
Republic of Korea, in 2015</title><author><name sortKey="Ryu, Boyeong" sort="Ryu, Boyeong" uniqKey="Ryu B" first="Boyeong" last="Ryu">Boyeong Ryu</name><affiliation><nlm:aff id="aff1"><institution>Seoul Center for Infectious Disease Control and Prevention</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Department of Epidemiology,<institution>Seoul National University School of Public Health</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Cho, Sung Il" sort="Cho, Sung Il" uniqKey="Cho S" first="Sung-Il" last="Cho">Sung-Il Cho</name><affiliation><nlm:aff id="aff1"><institution>Seoul Center for Infectious Disease Control and Prevention</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Department of Epidemiology,<institution>Seoul National University School of Public Health</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Oh, Myoung Don" sort="Oh, Myoung Don" uniqKey="Oh M" first="Myoung-Don" last="Oh">Myoung-Don Oh</name><affiliation><nlm:aff id="aff1"><institution>Seoul Center for Infectious Disease Control and Prevention</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation><affiliation><nlm:aff id="aff3">Department of Internal Medicine,<institution>Seoul National University College of Medicine</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Lee, Jong Koo" sort="Lee, Jong Koo" uniqKey="Lee J" first="Jong-Koo" last="Lee">Jong-Koo Lee</name><affiliation><nlm:aff id="aff1"><institution>Seoul Center for Infectious Disease Control and Prevention</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation><affiliation><nlm:aff id="aff4">Department of Family Medicine,<institution>Seoul National University College of Medicine</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Lee, Jaein" sort="Lee, Jaein" uniqKey="Lee J" first="Jaein" last="Lee">Jaein Lee</name><affiliation><nlm:aff id="aff5"><institution>Seoul Metropolitan Government Research Institute of Public Health and Environment</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Hwang, Young Ok" sort="Hwang, Young Ok" uniqKey="Hwang Y" first="Young-Ok" last="Hwang">Young-Ok Hwang</name><affiliation><nlm:aff id="aff5"><institution>Seoul Metropolitan Government Research Institute of Public Health and Environment</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Yang, Jeong Sun" sort="Yang, Jeong Sun" uniqKey="Yang J" first="Jeong-Sun" last="Yang">Jeong-Sun Yang</name><affiliation><nlm:aff id="aff6">Korea Centers for Disease Control and Prevention, Cheongju,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Kim, Sung Soon" sort="Kim, Sung Soon" uniqKey="Kim S" first="Sung Soon" last="Kim">Sung Soon Kim</name><affiliation><nlm:aff id="aff6">Korea Centers for Disease Control and Prevention, Cheongju,<country>Republic of Korea</country>.</nlm:aff></affiliation></author><author><name sortKey="Bang, Ji Hwan" sort="Bang, Ji Hwan" uniqKey="Bang J" first="Ji Hwan" last="Bang">Ji Hwan Bang</name><affiliation><nlm:aff id="aff1"><institution>Seoul Center for Infectious Disease Control and Prevention</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation><affiliation><nlm:aff id="aff7">Division of Infectious Diseases,<institution>Seoul Metropolitan Government-Seoul National University Boramae Medical Center</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</nlm:aff></affiliation></author></analytic><series><title level="j">Western Pacific Surveillance and Response Journal : WPSAR</title><idno type="ISSN">2094-7321</idno><idno type="eISSN">2094-7313</idno><imprint><date when="2019">2019</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct></listBibl></div1></back></TEI><pmc article-type="brief-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Western Pac Surveill Response J</journal-id><journal-id journal-id-type="iso-abbrev">Western Pac Surveill Response J</journal-id><journal-id journal-id-type="publisher-id">WPSAR</journal-id><journal-title-group><journal-title>Western Pacific Surveillance and Response Journal : WPSAR</journal-title></journal-title-group><issn pub-type="ppub">2094-7321</issn><issn pub-type="epub">2094-7313</issn><publisher><publisher-name>World Health Organization</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">31720054</article-id><article-id pub-id-type="pmc">6831962</article-id><article-id pub-id-type="publisher-id">wpsar.2019.10.2-046</article-id><article-id pub-id-type="doi">10.5365/wpsar.2018.9.3.002</article-id><article-categories><subj-group subj-group-type="heading"><subject>Non theme issue</subject><subj-group subj-group-type="article-subtype"><subject>Brief Report</subject></subj-group></subj-group></article-categories><title-group><article-title>Seroprevalence of Middle East respiratory syndrome coronavirus
(MERS-CoV) in public health workers responding to a MERS outbreak in Seoul,
Republic of Korea, in 2015</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Ryu</surname><given-names>Boyeong</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref><xref ref-type="aff" rid="aff2"><sup>b</sup></xref></contrib><contrib contrib-type="author"><name><surname>Cho</surname><given-names>Sung-Il</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref><xref ref-type="aff" rid="aff2"><sup>b</sup></xref></contrib><contrib contrib-type="author"><name><surname>Oh</surname><given-names>Myoung-don</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref><xref ref-type="aff" rid="aff3"><sup>c</sup></xref></contrib><contrib contrib-type="author"><name><surname>Lee</surname><given-names>Jong-Koo</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref><xref ref-type="aff" rid="aff4"><sup>d</sup></xref></contrib><contrib contrib-type="author"><name><surname>Lee</surname><given-names>Jaein</given-names></name><xref ref-type="aff" rid="aff5"><sup>e</sup></xref></contrib><contrib contrib-type="author"><name><surname>Hwang</surname><given-names>Young-Ok</given-names></name><xref ref-type="aff" rid="aff5"><sup>e</sup></xref></contrib><contrib contrib-type="author"><name><surname>Yang</surname><given-names>Jeong-Sun</given-names></name><xref ref-type="aff" rid="aff6"><sup>f</sup></xref></contrib><contrib contrib-type="author"><name><surname>Kim</surname><given-names>Sung Soon</given-names></name><xref ref-type="aff" rid="aff6"><sup>f</sup></xref></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Bang</surname><given-names>Ji Hwan</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref><xref ref-type="aff" rid="aff7"><sup>g</sup></xref></contrib><aff id="aff1"><label>a</label><institution>Seoul Center for Infectious Disease Control and Prevention</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</aff><aff id="aff2"><label>b</label>Department of Epidemiology,<institution>Seoul National University School of Public Health</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</aff><aff id="aff3"><label>c</label>Department of Internal Medicine,<institution>Seoul National University College of Medicine</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</aff><aff id="aff4"><label>d</label>Department of Family Medicine,<institution>Seoul National University College of Medicine</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</aff><aff id="aff5"><label>e</label><institution>Seoul Metropolitan Government Research Institute of Public Health and Environment</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</aff><aff id="aff6"><label>f</label>Korea Centers for Disease Control and Prevention, Cheongju,<country>Republic of Korea</country>.</aff><aff id="aff7"><label>g</label>Division of Infectious Diseases,<institution>Seoul Metropolitan Government-Seoul National University Boramae Medical Center</institution>,<addr-line>Seoul</addr-line>,<country>Republic of Korea</country>.</aff></contrib-group><author-notes><corresp id="cor1">Correspondence to Ji Hwan Bang (email: <email xlink:href="roundbirch@gmail.com">roundbirch@gmail.com</email>).</corresp></author-notes><pub-date pub-type="collection"><season>Apr-Jun</season><year>2019</year></pub-date><pub-date pub-type="epub"><day>06</day><month>6</month><year>2019</year></pub-date><volume>10</volume><issue>2</issue><fpage>46</fpage><lpage>48</lpage><permissions><copyright-statement>(c) 2019 The authors; licensee World Health
Organization.</copyright-statement><copyright-year>2019</copyright-year><license license-type="open-access"><license-p>This is an open access article distributed under the terms of the
Creative Commons Attribution IGO License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/3.0/igo/legalcode">http://creativecommons.org/licenses/by/3.0/igo/legalcode</ext-link>),
which permits unrestricted use, distribution, and reproduction in any
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this article there should not be any suggestion that WHO or this article
endorse any specific organization or products. The use of the WHO logo is
not permitted. This notice should be preserved along with the article's
original URL.</license-p></license></permissions></article-meta></front><body><p>The first case of Middle East respiratory syndrome coronavirus (MERS-CoV) in the Republic
of Korea was confirmed in May 2015 after a traveller returned from the Middle East.
(<xref rid="R1" ref-type="bibr"><italic>1</italic></xref>) There were 186 cases,
including 38 deaths, within two months. (<xref rid="R1" ref-type="bibr"><italic>1</italic></xref>) The potential of a single MERS-confirmed patient to
result in such a large MERS outbreak constitutes a serious global health concern. (<xref rid="R2" ref-type="bibr"><italic>2</italic></xref>)</p><p>During this MERS outbreak, massive public health containment measures were enacted at
various levels; these included epidemiological investigations, isolation of suspected
and confirmed cases, contact tracing and home quarantine of contacts. Local public
health centre (LPHC) and emergency medical services (EMS) personnel responded to the
outbreak by conducting initial interviews with suspected cases, transporting patients
and specimens and managing contacts. Responders in contact with patients used different
levels of personal protective equipment (PPE). Full-protection PPE includes a gown, N95
respirator, gloves and goggles. As the transmissibility of MERS is unclear, (<xref rid="R3" ref-type="bibr"><italic>3</italic></xref>) it is possible that responders
were infected by being exposed to MERS patients.</p><p>We conducted a cross-sectional study in January 2016 to assess whether LPHC and EMS
workers were infected and to determine their degree of exposure. The participants had
contact with MERS-confirmed patients or their specimens during the outbreak and
volunteered to participate in this study. The survey, which was a face-to-face
interview, examined subjects’ general characteristics, professional
responsibilities, contact history, symptoms after exposure and use of PPE.</p><p>Contact was defined as meeting at least one of the following four criteria: (<xref rid="R4" ref-type="bibr"><italic>4</italic></xref>) being within 2m of a confirmed
patient, staying in the same space as a confirmed patient for over 5 minutes,
contact with a patient’s respiratory or digestive secretions and contact with
specimens from confirmed patients before the sample was packaged. Contact within the
same space was graded into four levels according to distance of contact and wearing of
PPE. Without full PPE protection: Grade 1 was defined as contact within 2m, and Grade 2
was defined as contact at over 2m. With full PPE protection: Grade 3 was defined as
contact within 2m, and Grade 4 was defined as contact at over 2m.</p><p>Serum collected from all participants was screened for the presence of MERS-CoV IgG using
enzyme-linked immunosorbent assays (ELISAs). One sample with borderline results and five
samples with negative ELISA results were retested using indirect immunofluorescence
(IIFT) and plaque reduction neutralization (PRNT) tests for confirmation. The indirect
ELISA and MERS-CoV IIFT used commercial MERS-CoV IIFT slides (EUROIMMUN, Lübeck,
Germany) and followed the manufacturer’s protocol. Analysis was performed using a
DE/Axio Imager M1 immunofluorescence microscope (Zeiss, Jena, Germany). The PRNT was
performed as previously described. (<xref rid="R5" ref-type="bibr"><italic>5</italic></xref>) The number of plaques per well were counted; reductions
in plaque counts of 50% (PRNT50) and 90% (PRNT90) were calculated using the
Spearman-Kärber formula. (<xref rid="R5" ref-type="bibr"><italic>5</italic></xref>)</p><p>Thirty-four workers participated in the study (<xref rid="T1" ref-type="table"><bold>Table 1</bold></xref>): 31 from 11 LPHCs and three from two EMS
units. Twenty (58.8%) responders were male; their mean age was 44 (34–56.7)
years. Twenty-five participants (73.5%) occupied health-related positions: 11 (32.4%)
general health-care staff, 6 (17.6%) nurses, 4 (11.8%) doctors, 3 (8.8%) paramedics and
1 medical laboratory technologist (2.6%). Nine participants (26.5%) were
non-health-related workers: 5 (14.7%) technicians, 2 (5.9%) administrators, 1 (2.9%)
agricultural worker and 1 (2.9%) unknown.</p><table-wrap id="T1" orientation="portrait" position="float"><label>Table 1</label><caption><title>Exposure to MERS-confirmed patients
(<italic>n</italic> = 34)</title></caption><table frame="hsides" rules="groups"><col width="185" span="1"></col><col width="22" span="1"></col><col width="40" span="1"></col><thead><tr><th valign="middle" align="left" scope="col" rowspan="1" colspan="1">Exposure</th><th valign="middle" align="center" scope="col" rowspan="1" colspan="1"><italic>n</italic></th><th valign="middle" align="center" scope="col" rowspan="1" colspan="1">(%)</th></tr></thead><tbody><tr><td colspan="3" valign="top" align="left" scope="col" rowspan="1"><bold>Grade of
contact</bold></td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Grade 1</td><td valign="top" align="center" rowspan="1" colspan="1">7</td><td valign="top" align="center" rowspan="1" colspan="1">(20.6)</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Grade 2</td><td valign="top" align="center" rowspan="1" colspan="1">3</td><td valign="top" align="center" rowspan="1" colspan="1">(8.8)</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Grade 3</td><td valign="top" align="center" rowspan="1" colspan="1">20</td><td valign="top" align="center" rowspan="1" colspan="1">(58.8)</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Grade 4</td><td valign="top" align="center" rowspan="1" colspan="1">4</td><td valign="top" align="center" rowspan="1" colspan="1">(11.8)</td></tr><tr><td colspan="3" valign="top" align="left" scope="col" rowspan="1"><bold>Longest period
of contact</bold></td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> < 30
minutes</td><td valign="top" align="center" rowspan="1" colspan="1">13</td><td valign="top" align="center" rowspan="1" colspan="1">(38.2)</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> 30 minutes to
1 hour</td><td valign="top" align="center" rowspan="1" colspan="1">10</td><td valign="top" align="center" rowspan="1" colspan="1">(29.4)</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> 1 to
2 hour(s)</td><td valign="top" align="center" rowspan="1" colspan="1">6</td><td valign="top" align="center" rowspan="1" colspan="1">(17.6)</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> 2 to
5 hours</td><td valign="top" align="center" rowspan="1" colspan="1">5</td><td valign="top" align="center" rowspan="1" colspan="1">(14.7)</td></tr><tr><td colspan="3" valign="top" align="left" scope="col" rowspan="1"><bold>Activity
(<italic>n</italic> = 67)*</bold></td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Patient
transport</td><td valign="top" align="center" rowspan="1" colspan="1">24</td><td valign="top" align="center" rowspan="1" colspan="1">(35.8)</td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Patient
counselling</td><td valign="top" align="center" rowspan="1" colspan="1">10</td><td valign="top" align="center" rowspan="1" colspan="1">(14.9)</td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Ambulance
disinfection</td><td valign="top" align="center" rowspan="1" colspan="1">10</td><td valign="top" align="center" rowspan="1" colspan="1">(14.9)</td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Specimen
transportation</td><td valign="top" align="center" rowspan="1" colspan="1">8</td><td valign="top" align="center" rowspan="1" colspan="1">(11.9)</td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Respiratory
specimen collection</td><td valign="top" align="center" rowspan="1" colspan="1">7</td><td valign="top" align="center" rowspan="1" colspan="1">(10.4)</td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Taking vital
signs</td><td valign="top" align="center" rowspan="1" colspan="1">4</td><td valign="top" align="center" rowspan="1" colspan="1">(6.0)</td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Discarding
exposed goods</td><td valign="top" align="center" rowspan="1" colspan="1">3</td><td valign="top" align="center" rowspan="1" colspan="1">(4.5)</td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Other</td><td valign="top" align="center" rowspan="1" colspan="1">1</td><td valign="top" align="center" rowspan="1" colspan="1">(1.5)</td></tr><tr><td valign="middle" colspan="3" align="left" scope="col" rowspan="1"><bold>Symptoms
after contact</bold></td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Yes</td><td valign="top" align="center" rowspan="1" colspan="1">1</td><td valign="middle" align="center" rowspan="1" colspan="1">(2.9)</td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> No</td><td valign="top" align="center" rowspan="1" colspan="1">33</td><td valign="middle" align="center" rowspan="1" colspan="1">(97.1)</td></tr><tr><td valign="middle" colspan="3" align="left" scope="col" rowspan="1"><bold>PPE
education</bold></td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Received</td><td valign="top" align="center" rowspan="1" colspan="1">29</td><td valign="middle" align="center" rowspan="1" colspan="1">(85.3)</td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Not
received</td><td valign="top" align="center" rowspan="1" colspan="1">5</td><td valign="middle" align="center" rowspan="1" colspan="1">(14.7)</td></tr><tr><td valign="middle" colspan="3" align="left" scope="col" rowspan="1"><bold>Training in
wearing PPE</bold></td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Received</td><td valign="top" align="center" rowspan="1" colspan="1">20</td><td valign="middle" align="center" rowspan="1" colspan="1">(58.8)</td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Not
received</td><td valign="top" align="center" rowspan="1" colspan="1">13</td><td valign="middle" align="center" rowspan="1" colspan="1">(38.2)</td></tr><tr><td valign="middle" align="left" scope="row" rowspan="1" colspan="1"> Unknown</td><td valign="top" align="center" rowspan="1" colspan="1">1</td><td valign="middle" align="center" rowspan="1" colspan="1">(2.9)</td></tr></tbody></table><table-wrap-foot><p>* The 34 study participants performed multiple activities.</p><p>PPE: personal protective equipment.</p></table-wrap-foot></table-wrap><p>Based on the highest risk contact for each participant, seven (20.6%) of the responders
were classified as Grade 1; they were partially protected with at least gloves and an
N95 respirator (<xref rid="T1" ref-type="table"><bold>Table 1</bold></xref>).
They contacted asymptomatic or symptomatic patients, and symptomatic patients wore
surgical masks. After MERS-CoV had been confirmed in a patient, all staff were fully
protected when in contact with the patient. The closest contact occurred when touching
and holding patients during transport. One responder wearing full PPE had a mild fever
(37.5 °C) after contact with a symptomatic patient who was later confirmed as
infected. Since the response system had not expanded in the early days of the outbreak,
she was not tested but was isolated with self-monitoring.</p><p>Serum samples were obtained from all 34 participants at an average of 7.3 months
(range: 6.7–8.1 months) after exposure. On ELISA, there were 33 (97.1%)
negative results and one borderline result. The results of six samples, including one
with borderline ELISA results, were negative in the IIFT and PRNT.</p><p>In our study, we could not find evidence of MERS infection in the public health providers
after direct contact with confirmed patients. This may be because there was a lower risk
of transmission when participants were transporting or counselling patients outside of
the hospital compared to providing medical assistance within the hospital. In other MERS
outbreaks, secondary infections were related to health-care settings. (<xref rid="R1" ref-type="bibr"><italic>1</italic></xref>, <xref rid="R6" ref-type="bibr"><italic>6</italic></xref>) Although the exact route of infection transmission
is unknown, aerosolizing procedures in crowded rooms with inadequate infection
prevention and control measures were observed in health-care settings. (<xref rid="R7" ref-type="bibr"><italic>7</italic></xref>) In the 2015 Republic of Korea
outbreak, some health-care workers without proper PPE were infected in tertiary
hospitals, thus emphasizing the optimal use of PPE to prevent MERS infection. (<xref rid="R8" ref-type="bibr"><italic>8</italic></xref>) Moreover, since the participants
did not contact any spreaders except one participant who contacted a patient that caused
two secondary infections, the risk of transmission from the contacted patients was
likely low.</p><p>This study had several limitations. First, the survey was conducted 7.3 months
after the MERS outbreak, making recall bias possible. Second, it is possible that we
missed some mild or asymptomatic cases. Furthermore, because the serological tests were
performed several months post-exposure, pre-existing MERS antibodies may have decreased
or disappeared in the interval, potentially leading to underestimation. While
asymptomatic MERS infection had been detected using RT–PCR testing at the time of
outbreak, (<xref rid="R9" ref-type="bibr"><italic>9</italic></xref>) a Saudi Arabian
study showed the longevity of MERS-CoV antibodies in MERS patients varied in the
severity of illness. For example, antibodies in severely infected patients persisted
after 18 months, but milder and subclinical cases detected no antibodies even early on
in the disease. (<xref rid="R10" ref-type="bibr"><italic>10</italic></xref>) Third, the
number of participants was relatively small and may not be representative or
generalizable. Despite these limitations, this study suggests that the risk of MERS
transmission to public health professionals responding to MERS outside the hospital
setting (i.e. patients’ homes) was low, particularly for those who wore some
level of PPE such as masks and gloves. Further study is needed to prospectively survey
public health responders including symptomatic or asymptomatic cases to conduct genetic
test and serologic test during an outbreak.</p><p>In conclusion, the public health providers in our study did not have evidence of MERS
transmission after direct contact with confirmed patients when PPE was used
properly.</p><sec disp-level="2"><title>Ethics</title><p>Ethical approval for the study was obtained from the institutional review board
of Seoul National University Hospital in Seoul (IRB No.
C-1512–049–727).</p></sec></body><back><ack><title>Acknowledgements</title><p>We would like to thank the study participants and the Division of Life and Health of
the Seoul Metropolitan Government for assistance with the research.</p></ack><fn-group><title>Funding information</title><fn fn-type="supported-by"><p>This study was supported by the Seoul Metropolitan Government and a fund
(#4834-300-210-13) of Korea Centers for Disease Control and Prevention,
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