SARS

1
SARS

• Swedish Medical Center
• 2004
• Will Shelton, M(ASCP), CIC

2
Goals and Objectives

• Participants will be able to describe why SARS
  can re-emerge
• With handouts or available resources participants
  can describe clinical aspects of SARS
• Participants will know where to find CDC
  Guideline for Preparedness and Response in
  Healthcare Facilities
• Provide tools and examples to participants to
  help meet recommendations in third bullet

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What I am not going to do

• I will not list and go over every part of the CDC
  guideline.Ill be honest. At SMC we are using a
  spreadsheet of tasks and assignments to meet the
  CDC guidelines and it is 10 Excel pages long! We
  formed a committee with
• COO as Executive Sponsor
• VP of RN Operations as Chair
• Infection Control as Facilitator

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Along the way

• I will share some absolute trivia that you dont
  need to know which fascinated me while preparing
  myself to understand SARS and create this lecture

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References

• www.cdc.gov
• SARS, Community Level Preparedness for response
  to Severe Acute Respiratory Syndrome (SARS)
• http//www.who.int/en/
• http//www.metrokc.gov/health.htm
• http//www.dhhs.state.nc.us/dph/sars/state_sars_pl
  an.htm
• www.health.gov.on.ca

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Planning GoalYou and I have a RESPONSIBILITY

• Protect the healthcare community from SARS
• Patients
• Healthcare Workers (HCWs)
• Visitors

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SARS Diagnostics Electron Microscopy
C Humphrey, Pathology Activity Program
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Severe Acute Respiratory Syndrome Chronology

• SEPT 2003 8423 cases (916 deaths) reported from
  29 countries 11 case fatality rate, range 0 to
  gt50
• Country Cases Deaths
• China 5327 349
• Hong Kong 1755 300
• Taiwan 665 180
• Canada 251 41
• Singapore 239 33
• Viet Nam 63 5
• USA 33 0

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Will SARS Re-emerge?

• Potential sources of re-emergence
• Animal reservoir
• Humans with persistent infection
• Unrecognized transmission in humans
• Laboratory exposure
• SARS most likely to recur outside U.S.
• Well-established global surveillance is important
  to recognition of first case

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Prevalence of SARS Antibody in Animal Traders,
Guangdong Province, 2003MMWR52 2003, p486
Group tested positive
Animal traders 508 13
Hospital workers 137 4
Healthy adults in clinic 84 1.2
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Prevalence of SARS Antibody in Animal Traders by
Animal traded MMWR52 2003, p486
Animal traded Traders Positive
Masked palm Civet 22 72.7
Wild Boar 28 57.1
Muntjac Deer 16 56.3
Hare 13 46.2
Pheasant 9 33.3
Cat 42 18.6
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• Taxonomy Kingdom Animalia (Animals)
• Phylum Chordata (Animals with notochords)
• Subphylum Vertebrata (Chordates with backbones)
• Class Mammalia (Vertebrates with hair that
  produce milk)
• Subclass Eutheria (placental mammals)
• Order Carnivora (Carnivores)
• Superfamily Feliodea/Aeluroidea (Feline-like
  carnivores also includes hyenas and civets)
• Family Viverridae (Civets)
• Subfamily Cryptoproctinae (Fossa)
• Subfamily Euplerinae (Malagasy civets)
• Subfamily Hemigalinae (Banded palm civets)
• Subfamily Nandiniinae (African Palm Civet)
• Subfamily Paradoxurinae (Palm Civets)
• Subfamily Viverrinae (Genets, Linsangs, Oriental
  Civets)

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Viverrids have, in general, long lithe bodies set
on short legs. The length of the tail in most
species equals the body length. Most species'
heads are long and pointed, with rounded ears set
high on the head. Their eyes are typically
vertically ovular or slits, like feline cats or
vulpine foxes. Most species have spots on their
bodies and stripes on their tails. They have
retractable or semi-retractable claws. They have
glands near their genitals, called perineal
glands, that produce a strong odor civets have
been used for centuries in making perfume. They
lack anal glands. Males, like most carnivores,
have a baculum, a bony-like structure in the
penis. Viverrids have 32-40 teeth. They are, for
the most part, nocturnal, solitary creatures.
Their diet is omnivorous, and most viverrids will
eat a variety of plant and animal matter. The
majority of viverrids are arboreal.
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When you dont have a refrigerator, live is fresh!
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Effect of Travel and Missed Cases on the SARS
Epidemic Spread from Hotel M, Hong Kong
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SARS Transmission is Heterogenous
Probable cases of SARS by reported source of
infection, Singapore, Feb 25 Apr 30
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• What would happen today if a patient with
  symptoms of SARS presented to your Emergency
  Department or outpatient office?

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Friday, March 7th
SGH
Index Case
Patient A
(Mother)
(Son)
Admitted to SGH
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Night of March 7th
Observation Unit ER SGH
Patient A
Patient B
Patient C
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Toronto Hospital Emergency Department March 16
2245-2330
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SARS 2 - NYGH
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Total SARS Cases and Healthcare Workers by
Country
HCW
Total No. SARS cases
HCW
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What have we learned?

• SARS transmission
• Primarily through close contact with infected
  persons
• Droplet spread most likely
• Cannot rule out fomites and possibility of
  airborne spread
• Intensity of exposure during aerosol-generating
  procedures may increase transmission risks

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What have we learned?

• SARS transmission risks are primarily from
• Unprotected exposures to unrecognized cases in
  both inpatient and outpatient settings.
• We must look beyond the patient contacts may be
  infectious too.
• Prevention begins when a patient or visitor walks
  through the door of an Emergency Department, an
  outpatient office or the hospital.

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Clinical Aspects of Severe Acute Respiratory
Syndrome (SARS)

• Incubation period 2-10 days
• Median 4-6
• Rarely up to 14 days?
• Onset of fever, chills/rigors, headache,
  myalgias, malaise
• Fever may resolve prior to respiratory symptoms
• Diarrhea has been a prominent feature of early
  illness in some
• Respiratory symptoms often begin 3-7 days after
  symptom onset, peak in second week
• 30 have respiratory symptoms at onset

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Symptoms Commonly Reported By Patients Presenting
with SARS

• Symptom Range ()
• Fever 95-100
• Cough 57-100
• Dyspnea 20-100
• Chills/Rigor 73-90
• Myalgias 20-83
• Headache 20-70
• Diarrhea 10-67
• Nausea/Vomiting 10-24
• (Rhinorrhea) 5-25
• (Sore Throat) 5-25

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Common Clinical Findings in Patients with SARS
Finding Range ()
Physical Examination Rales/Rhonci Hypoxia 38-90 60-83
Laboratory Leukopenia Lymphopenia Thrombocytopenia Prolonged aPTT Increased ALT Increased LDH Increased CPK 17-34 70-95 30-50 40-60 20-30 70-94 30-40
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Severe Acute Respiratory Syndrome Chest
Radiograph and CT

• Up to 30 normal at presentation
• Infiltrates subsequently develop in nearly all
  laboratory confirmed cases
• 66 by day 3 97 by day 7 100 by day 10
• A substantial proportion of cases show early
  focal interstitial infiltrates progressing to
  more generalized, patchy interstitial infiltrates
• Focal consolidation
• HRCT Ground-glass opacification with or without
  thickening of the intra-lobular or interlobular
  interstitium /- consolidation

Wong. Radiology 2003228401-6 Wang. Proceedings
of International Science Symposium on SARS.
Beijing, China, 2003 Xue. Chin Med J
2003116819-822 Zhao. J Med Microbiol
200352715-20. Rainer. BMJ 20033261354-8.
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Lee N. et al NEJM 4/7/03
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Lee N. et al NEJM 4/7/03
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Severe Acute Respiratory Syndrome
25 y.o woman with ill defined air space
shadowing. Source A Major Outbreak of Severe
Acute Respiratory Syndrome in Hong Kong. Lee, et
al. Published at www.nejm.org April 7, 2003
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Severe Acute Respiratory Syndrome
Case 6 Patchy consolidation in right lower lung
zone Source A Cluster of Cases of Severe Acute
Respiratory Syndrome in Hong Kong. Tsang, et al.
Published at www.nejm.org April 7, 2003
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Severe Acute Respiratory Syndrome
76 y.o. man, 9 days after symptom onset, No.
2 Source Identification of Severe Acute
Respiratory Syndrome in Canada Poutanen, et. Al.
. Published at www.nejm.org March 31, 2003
35
Severe Acute Respiratory Syndrome
76 y.o. man, 10 days after symptom onset, No.
3 Source Identification of Severe Acute
Respiratory Syndrome in Canada Poutanen, et. Al.
. Published at www.nejm.org March 31, 2003
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Laboratory Diagnosis of SARS

• Ability to detect SARS CoV early in illness
  limited
• Low titer of virus in early specimens
• lt 50 positive by PCR 1st week
• Testing multiple specimens may improve ability to
  diagnose
• Respiratory, stool, serum/plasma
• Stool may be best
• Antibody response can take up to 28 days
• Detectable as early as 10-14 days
• False positive PCR assays a concern

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Peiris personal communication
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Rationale for Limiting SARS-CoV TestingIn
setting of no or limited SARS activity
IF Sensitivity of detecting SARS in clinical
specimen 50 Specificity of test 95
Prevalence 50 PPV 95
PPV
Prevalence 1 PPV 9
Prevalence of SARS among persons tested
PPVpositive predictive value
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Preparing for SARS Key Clinical Concepts

• Non-specific clinical presentation
• difficult to distinguish from other respiratory
  diseases
• No rapid diagnostic test exists that can reliably
  detect infection early in the illness
• Nearly all laboratory-confirmed cases have X-ray
  evidence of pneumonia by day 7 of illness

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Management of Fever and Respiratory Symptoms in
the Absence of SARS Activity Worldwide

• Maintain low index of suspicion, use CDC
  screening criteria
• Screen all patients hospitalized with
  radiographically-documented pneumonia
• 1) Does the patient have a history of recent
  travel (in the 10 days before illness onset) to
  previously SARS affected areas, or have close
  contact with ill persons with a history of travel
  to a such an area?
• 2) Is the patient employed as a health care
  worker with direct patient contact?
• 3) Does the patient have close contacts recently
  diagnosed with pneumonia without an alternative
  diagnosis?
• Report to public health and hospital infection
  control all cases answering yes to one of the
  above, and clusters of unexplained pneumonia

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Management of Fever and Respiratory Symptoms in
the Absence of SARS Activity Worldwide

• In the absence of SARS activity worldwide,
  droplet precautions are recommended for persons
  with respiratory tract infections who meet SARS
  screening criteria
• Higher levels of isolation precautions are
  recommended in the presence of SARS activity
  worldwide, but are not routinely recommended in
  the absence of SARS activity worldwide

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Management of Fever and Respiratory Symptoms
Regular mask placed on patient with fever and or
respiratory symptoms.
Droplet Precautions healthcare worker wears mask
with eye protection in addition to Standard
Precautions
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After SARS Transmission Documented Anywhere in
the WorldYes, it has been documented but CDC
Who say not enough for us to go to this yet

• Any patient with either fever OR respiratory
  symptoms should be asked about
• Recent exposure to a SARS-affected area or close
  contact with ill persons with exposure to such
  areas (foreign or domestic)
• Recent exposure to a person suspected of having
  SARS
• Healthcare worker

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After SARS Transmission Documented Anywhere in
the World

• If fever OR respiratory symptoms AND has at least
  one risk factor for exposure to SARS CoV
• Begin SARS isolation precautions, Airborne,
  Contact Droplet
• Notify local health department and person
  designated by plan
• Diagnostic workup - I suggest a kit with
  instructions
• Chest X-ray
• CBC with differential
• Pulse oximetry
• Blood cultures
• Sputum Grams stain and culture
• Testing for viral respiratory pathogens
• If pneumonia, then urinary antigen testing
  legionella and pneumococcal
• Other tests CPK, transaminase levels, LDH, aPTT,
  C-reactive protein
• IF SARS or Avian Influenza highly suspected-
  State Lab should do tests to assure proper P3 lab
  safety
• Follow clinical management algorithm

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Patient isolation

• Though most transmission appears to occur from
  infectious droplets, there are infrequent
  episodes where airborne transmission cannot be
  excluded.
• CDC recommends that SARS and Avian Influenza
  patients be managed with airborne, droplet
  contact precautions.

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Airborne isolation

• Potential SARS patients should be placed in
  airborne infection isolation or negative pressure
  rooms (AIIRs).
• Healthcare workers should wear a fit-tested N95
  (or higher) respirator or personal air purifying
  respirator (PAPR) in addition to gowns, gloves
  and eye protection.
• Cohorting

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Draft-Algorithm to Work Up and Isolate
Symptomatic Persons who may have been Exposed to
SARS
Fever or Respiratory Illness1 in Adults Who May
Have Been Exposed to SARS
Begin SARS isolation precautions, initiate
preliminary work-up notify Health Department2
- CXR
No Radiographic Evidence of Pneumonia
No Alternative Diagnosis
Alternative diagnosis confirmed3
Continue SARS isolation and re-evaluate 72 hours
after initial evaluation
Consider D/C SARS isolation precautions5
Symptoms improve or resolve
Persistent fever or unresolving respiratory
symptoms
Perform SARS test continue SARS isolation for
additional 72 hr. At end of the 72 hrs, repeat
clinical evaluation including CXR
CXR
No radiogrpahic evidence of pneumonia
Consider D/C SARS isolation precautions5
Use algorithm for CXR cases
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Draft- Algorithm to Work Up Isolate
Symptomatic Persons who may have been Exposed to
SARS
Fever or Respiratory Illness1 in Adults Who May
Have Been Exposed to SARS
Begin SARS isolation precautions, initiate
preliminary work-up notify Health Department2
Radiographic Evidence of Pneumonia
Perform SARS testing
Laboratory evidence of SARS-CoV or No
alternative diagnosis
Alternative diagnosis confirmed
Consider D/C SARS isolation precautions
Continue SARS isolation until 10 days following
resolution of fever given respiratory symptoms
are absent or resolving

• Using Alternative Diagnosis to Rule Out SARS
• Based on test with high positive predictive value
• Clinical course consistent
• No evidence of clustering
• No strong epidemiologic link

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SARS Preparedness Planning

• Preparedness Plan Elements
• Organizational infrastructure
• Logistics of patient care
• Staffing
• Durable and consumable resources
• Exposure management

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CDC-Components of Preparedness and Response in
Healthcare Facilities

• Surveillance and triage
• Clinical Evaluation of Patients
• Infection Control and Respiratory Etiquette
• Patient Placement, Isolation and Cohorting
• Engineering and Environmental Controls

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More Components of Preparedness

• Exposure Reporting and Evaluation
• Staffing Needs and Personnel Policies
• Hospital Access Controls
• Supplies and Equipment
• Communication and Reporting

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Prepare to make changes at the first point of
patient encounter

• Consider ways to prevent exposures.
• Visual alerts with instructions at entrances
• Designate sick and well waiting areas
• Create physical barriers between patients and
  triage/reception personnel
• Promote Respiratory Etiquette

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• If known cases of SARS in world
• Signage and screening at all entry points (many
  have this now)
• ER, Patient Registration
• All Hospital Outpatient Registration
• PT, OT, Med Img
• All OP Clinics
• If febrile and cough with travel, HCW or contact
  triage to screening area

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From Minn Public Health adapted by UW
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Promote Respiratory Etiquette

• Instruct ALL patients with respiratory symptoms
  to cover nose/mouth with tissue when coughing or
  sneezing
• Make hand hygiene products and tissues available
  in waiting areas
• Offer masks to symptomatic persons
• All this means educating your Patient
  Registration and front desk staff

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• Education
• PPE
• Recognition
• Isolation
• Where will they go
• How will you get them there
• How will you care for them when you get them
  there Treatment plan

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What have we learned?

• Use of PPE prevents transmissionhowever,
• Healthcare personnel need instruction on how to
  don, use and remove PPE
• Wearing PPE for extended periods of time is a
  burden and can lead to breaches in technique

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What have we learned?

• Advance planning is necessary to ensure the
  protection of HCWs, patients and visitors
• Segregating patients with symptoms from other
  patients may be challenging

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What should be our immediate priorities?

• Improve recognition and prevention of
  transmission at the initial point of patient
  encounter
• Improve availability of masks and hand antisepsis
  for staff and patients now
• Add use of respirators and more PPE if SARS or
  Avian Flu
• Improve PPE use practices - this means you have
  to fit test

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Prepare to make changes at the first point of
patient encounter

• Consider ways to prevent exposures.
• Visual alerts with instructions at entrances
• Designate sick and well waiting areas
• Create physical barriers between patients and
  triage/reception personnel
• Promote Respiratory Etiquette

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1st Step Promote Respiratory Etiquette

• Offer masks to symptomatic persons
• Instruct ALL patients with respiratory symptoms
  to cover nose/mouth with tissue when coughing or
  sneezing and how to properly dispose of tissues
• Have alcohol hand gel and tissues available in
  waiting areas to distribute to symptomatic
  patients
• Surgical masks with eye protection for staff who
  have contact with patients displaying respiratory
  symptoms

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Respiratory Etiquette cont

• Some patients may not be able to wear a mask
  comfortably if short of breath or will not
  cooperate
• Offer the patient a box of tissues to keep with
  them and reinforce proper use and disposal
• Triage the patient as quickly as possible to
  segregate from other patients in the waiting room
• wipe any environmental surfaces potentially
  contaminated with hospital approved cleaning
  agent before next patient

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Discharge Planning

• SARS or Avian Flu not requiring admission,
  exposed people, patients ready for DC but ?
  infectious
• Work with county or state to assure Quarantine
  and Isolation Plans
• King County has or will soon have Discharge Plan
  available on line at
• http//www.metrokc.gov/health.htm

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The King County Plan Includes

• IC Instructions for Home Isolation
• Guidelines for Eval of Home Isolation - an
  Inspection Checklist
• Assessment and symptom monitoring form
• SARS Hospital Discharge Instructions

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More King County Discharge Plan

• Quarantine or Isolation Letter
• Isolation, Quarantine, The Law You
• Copy of applicable WACs

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You are doing difficult complex but very valuable
work!

• You are not just planning for SARS
• We started with SARS, Avian Influenza is now
  added, more will come
• I believe all the work you are doing is building
  a stronger arm of your Hospital Emergency
  Incident Command System (HEICS) to deal with any
  highly communicable biologic event.

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