SARS Outbreak in Hong Kong

1
SARS Outbreak in Hong Kong

• Professor Peter Cameron
• Previously
• COS Prince of Wales Hospital
• Chinese University of Hong Kong

2
Background

• Aware of Reports of Atypical Pneumonia in
  Guangzhou
• Reported 305 cases and 5 deaths and then
  information ceased
• Thought that it was probably worse
• ? Chlamydia
• A couple of unusual cases admitted to HK
  hospitals died, no secondary spread

3
Index Case Prince of Wales

• Admitted Ward 8A, March 4, 2003
• 26 yo ethnic Chinese, symptoms of high fever,
  myalgia, and cough
• One ED attendance 4 days previously for fever and
  myalgia
• Diagnosed with pneumonia and treated with
  augmentin and clarithromycin
• Improved over one week
• No unusual features

4
Recognition of Outbreak

• Staff of 8A noticed a number of medical and
  Nursing staff sick
• ? Influenza Discussion regarding isolation
• Area with separate ventilation, entry from main
  wards
• ? ED Observation Ward
• Discussion with CEO, Prof Medicine and ED
• Establish Facts
• 15 medical and 15 Nursing staff sick
• 5 ED docs and 3 nurses
• Other pts and visitors
• Medical students

5
Response

• Symptomatic staff isolated to ED Observation Ward
• Not all staff complied
• ?over reacting
• CEO called council of war next morning of service
  chiefs then twice daily
• Hospital continued normal services initially
• 2-3 days to recognise internally the extent of
  the problem

6
Response

• Community aware that PWH had a problem within 2
  days
• Thought to be internal and government supported
  this view
• Did not ban visitors initially
• Balance between panic/service/managing an outbreak

7
Staff getting sicker
8
ED
9
Screening
10
Ward
11
Unknown

• Nature of organism
• Mode of spread
• Extent of spread
• Outcome
• Likely epidemiology
• ?world pandemic

12
Quarantine

• Intense lobbying by senior clinicians
• Staff afraid to go home at night
• Visitors
• Patients
• Elective
• Specialist
• Emergency
• Possible cases
• Home vs ward isolation
• Screening procedures

13
Reported Clinical Features(Inpatients)

• Incubation period 2-7 days but ?16 days
• Symptoms
• Fever 100
• Chills/rigors 73.2
• Myalgia 61
• Cough 57
• Headache 56
• Dizziness 43
• Also NV, diarrhea, abdo pain, coryza, sore thoat
  20

14
Initial Symptoms at a Screening Clinic

• SARS - SARS
• Fever 37 81
• Chills 21 52
• Malaise 20 34
• Myalgia 12 27
• Rigor 4 12
• Cough 72 64
• URI neg predictor
• LOA/Vomiting/Diarrhoea Pos Predictors

15
CT Changes
16
Epidemiology

• Contact tracing
• Health department processes not adequate
• Expertise?

17
Epidemiology Amoy Gardens
18
Graphic of epidemiology
19
Infection control

• Droplet spread
• Mask, glove, cap and gown
• Surfaces/fomites
• Hood/visor for procedures
• Viral filters
• Other modes of spread?
• Definite evidence of faecal/urine viral loads
• No evidence of airborne negative pressure
  unnecessary

20
Airborne Spread

• Nebulisers
• Non Invasive Ventilation
• Continuum between aerosol and droplet

21
Engineering

• Ventilation
• Toilet layout
• Sewage
• Negative pressure rooms
• Ward layouts

22
Treatment

• Empiric treatment
• Antivirals - ribavirin
• Steroids
• Cytokine inhibitors
• Convalescent serum
• Traditional chinese medicine
• Ethics?
• Political pressure

23
Staff Morale

• Service chiefs daily updates
• Staff forum daily
• Web site updates
• Daily ward round by senior staff
• CEO of hospital and Hospital Authority contracted
  disease
• Face to face meetings danger of cross infection
• HKSAR CEO perceived badly for not being on site

24
Families

• Important aspect of staff morale
• Should staff stay in quarters increased risk
  for staff
• Isolation of staff from families
• Possibility of months
• Send family away increased risk to other
  communities
• If staff go home what precautions needed?

25
Outcomes in PWH

• 20-30 of all pts in ICU
• No nursing or medical staff at PWH died
• gt100 staff and med students affected
• Initial mortality 5 but case fatality rate gt10
• In elderly gt50
• Long Term?
• Pulmonary fibrosis

26
Outcomes in HK

• 1700 cases
• 300 deaths
• Outbreak over in less than 3 months
• 25 cases staff

27
Graph of case fatality
28
Community Response

• Hospitals
• Initially PWH
• Other hospitals became involved
• Infectious disease hospital
• Overloaded

29
Community Response

• schools
• Tourist and economy
• Goverment

30
Schools?
31
Tourists economy?
32
Street sweeping
33
Living Life with a mask
34
Governments?
35
Wu and wen
36
Microbiology

• Uncertainty about organism
• Tests actually caused problems
• Not properly trialled for accuracy

37
Serologic confirmation of cases

• Coronavirus confirmed in virtually all those with
  classic course
• Very few cases with no symptoms and CoV serology
• Reason for immunity?
• Mucosal barrier
• IgA

38
Lessons Learnt

• Politics of Infectious disease ugly
• Little is known about infectious disease
• Basic infection control works
• Basic Infection control is not done well
• Hospital workers are at risk
• Authorities are always behind in managing
  disasters
• Dont try to predict nature
• Life Returns to normal quickly

39
Life Returns to normal quickly
40
Picture of front line
41
Venepuncture
42
Mona lisa with mask