What You Wanted to Know About Severe Acute Respiratory Syndrome (SARS)

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What You Wanted to Know About Severe Acute
Respiratory Syndrome(SARS)but were afraid to
ask

• Jaime C. Montoya, MD, MSc, FPCP, FPSMID

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SARS

• Associated with outbreak of atypical pneumonia in
  GuangDong, China in Nov 2002
• International spread from hotel in
  HongKong---Vietnam, United States, Singapore,
  Canada, Ireland

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According to the WHO,as of April 23, 2003,the
total number of casesof SARS worldwide is
4288with 251 deaths.(Death Rate 5.8)At
present, there has beenno confirmed case of SARS
identified in the Philippines.
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Distribution of Cases of SARS
Ireland
United Kingdom
France
Germany
Italy
Thailand
Canada
Taiwan
Switzerland
China
Singapore
United States
Hong Kong
Vietnam
Romania
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China (Mainland) Guangdong Province, Beijing,
and Shanxi 2305 cases, 106 deaths, with local
transmission
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China,Hong Kong Special Administrative Region
1458 cases, 105 deaths, with local transmission
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Asian Countries with SARS
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Countries with SARS
Due to differences in the case definitions being
at a national level, probable cases are reported
by all countries except the United States of
America, which is reporting suspect cases under
investigation.
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SARS Suspected Cases

• March 17 to April 1, 2003 (n25)
• Hospital admitted discharged
• RITM 5 3
• SLH 13
  11
• Region 1 3 0
• Region 7 1 0
• CAR 3
  0
• Total 25
  14

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SARS Suspected Cases

• Calls entertained through hotlines 1,500
• from March 17 to April 1, 2003

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Etiology of SARS

• A new member of Coronavirus isolated in 50 to
  60 of cases identified as the causative agent
• Human Metapneumovirus isolated in 25 of cases

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SARS Suspect Case Definition

• High fever (gt38OC)
• AND
• Cough, shortness of breath or difficulty of
  breathing
• AND
• 1. Close contact within 14 days of onset of
  symptoms, with a person diagnosed with SARS
• or
• 2. History of travel to SARS area within 14 days
  of onset of symptoms

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Probable SARS case

• Suspect case plus pneumonia or respiratory
  distress syndrome (RDS)
• OR
• Suspect case unexplained respiratory illness
  leading to death with autopsy finding of RDS
  without an identifiable cause.

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How do we determinewho has SARS?

• Signs and Symptoms
• cough
• difficulty of breathing
• fever (gt38 C 100.4 F)
• - chest x-ray results
• pneumonia or
• acute respiratory distress syndrome
• History of travel
• within 14 days of onset of symptoms to countries
  with SARS cases
• Close contact with persons diagnosed with SARS

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Epidemiological factors

• Health Care Workers and close contacts at high
  risk
• Strict isolation and infection control to halt
  spread
• However, community spread in HK, airline spread
• Supertransmitters? (e.g.dialysis px, elderly)

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SARS transmission

• SARS can be transmitted from person to person by
  droplet infection.
• SARS cases, when they cough, can spread droplets
  with the infective organism to a distance of
  approximately one meter or three feet.
• SARS can not be transmitted by mosquitoes or
  other insects and animals.

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Stages of SARS

• Exposure to SARS
• I.P. phase Prodrome
  Lower Respiratory
• 1-13 days 2 days
  begins day 3
• (2 to 5 days) fever (gt38 C)
  fever, dry cough,
• 
  shortness of breath
• 
  chest x-ray changes
• Infectivity
• very low/low? Low
  High/super-infectors?

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Clinical picture in SARS patients
Recovery approx 90
Acute respiratory distress syndrome approx 10
Infectivity
None /very low
Low
Very high
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Clinical Features

• severe respiratory phase
• intubation/mech
  vent
• 10 death lt 4
• 90 Continued illness
• O2 support/slow
  recovery
• In the first 10 patients in HK, only 1 px dc off
  supplemental O2 day 12 CXR resolution day 18
  d/c day 20 still with malaise day 28 infectivity
  unclear, possibly high to very high patient
  still isolated on d/c

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Prince of Wales Hospital, Hong Kong

• Clinical features of 138 secondary tertiary
  cases
• Fever 100 (high grade, persistent)
• Chills/rigor 73
• Myalgia 61
• Dry cough 57
• Headache 56
• Dizziness 43

Lee N et al. www.nejm.org April 7, 2003
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Laboratory findings
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Chest x-ray appearances

• Opacities are predominantly found in the lower
  lung zones
• Pleural effusions not seen
• Could be rapidly progressive and might need twice
  daily CXRs

Tsang K et al www.nejm.org March 31, 2003
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Can we keep the Philippines SARS-free?

• For how long?

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Triage Algorithm for SARS

• Does the patient have ----gtY---gtHas fever gt38 C
  developed---gt Y---gt Isolate and
• a recent hx of travel? Within
  14 days of leaving
  investigate
• 
  affected area or contact
• 
  with a known SARS px
• No
  No
  Y
• No Is
  patient still within IP for Y Gen info
  about personal
• 
  SARS (14 days) following surveillance
  for fever
• 
  travel/contact with SARS case? During IP
• 
  
  Treat nonSARS
• Provide info about SARS
  medical
  illness
• Treat Non SARS medical illness

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Advisory on Quarantine

• Persons symptomatic on arrival
• Direct to airport or maritime quarantine station
• Refer to hospitals (San Lazaro or RITM or
  regional hospitals)
• Persons asymptomatic on arrival
• If with contact with SARS case
• Advise Voluntary Home Confinement
• Limit contact with members of the household
• Call DOH hotlines once signs and symptoms
  indicative of SARS appear within 14 days after
  arrival
• If without known contact with SARS case
• Call DOH hotlines once signs and symptoms
  indicative of SARS appear within 14 days after
  arrival

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Do not worryIf you did not travel to countries
with SARS cases in February to MarchIf you did
travel to countries with SARS cases but did
notcome near a known case of SARS
PUBLIC ADVISORY
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For inquiries, call741-7048or743-1937or
text your questions at0916-466-5823
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List of Medical Centersand Regional Hospitals

• Metro Manila
• CITY OF MANILA
• SAN LAZARO HOSPITAL
• MUNTINLUPA CITY
• RESEARCH INSTITUTE FOR
• TROPICAL MEDICINE

• Region I
• SAN FERNANDO, LA UNION
• ILOCOS TRAINING AND
• REGIONAL MEDICAL CENTER
• BATAC, ILOCOS NORTE
• MARIANO MARCOS MEMORIAL
• HOSPITAL AND MEDICAL CENTER

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List of Medical Centersand Regional Hospitals

• Region II
• BAYOMBONG, NUEVA VIZCAYA
• VETERANS REGIONAL HOSPITAL
• TUGUEGARAO, CAGAYAN
• CAGAYAN VALLEY MEDICAL CENTER

• Region III
• SAN FERNANDO, PAMPANGA
• JOSE B. LINGAD MEMO.
• GENERAL HOSPITAL
• CABANATUAN, NUEVA ECIJA
• DR. PAULINO GARCIA MEMORIAL
• RESEARCH AND MEDICAL CENTER

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List of Medical Centersand Regional Hospitals

• Region IV
• BATANGAS CITY, BATANGAS
• BATANGAS REGIONAL HOSPITAL

• Region V
• LEGASPI CITY, ALBAY
• BICOL REGIONAL TRAINING
• AND TEACHING HOSPITAL
• NAGA CITY, CAMARINES SUR
• BICOL MEDICAL CENTER

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List of Medical Centersand Regional Hospitals

• Region VI
• BACOLOD CITY, NEGROS OCCIDENTAL
• WESTERN VISAYAS REGIONAL HOSPITAL
• MANDURRIAO, ILOILO CITY
• WESTERN VISAYAS MEDICAL CENTER

• Region VII
• TAGBILIRAN CITY, BOHOL
• GOV. CELESTINO GALLARES
• MEMORIAL HOSPITAL
• CEBU CITY
• VICENTE SOTTO SR. MEMORIAL
• MEDICAL CENTER

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List of Medical Centersand Regional Hospitals

• Region VIII
• TACLOBAN CITY, LEYTE DEL NORTE
• EASTERN VISAYAS REGIONAL MEDICAL CENTER

• Region IX
• DAPITAN CITY, ZAM. DEL NORTE
• DR. JOSE RIZAL MEMORIAL HOSPITAL
• MARGOSATUBIG, ZAM. DEL SUR
• MARGOSATUBIG REGIONAL HOSPITAL
• ZAMBOANGA CITY, ZAM. DEL SUR
• ZAMBOANGA CITY MEDICAL CENTER

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List of Medical Centersand Regional Hospitals

• Region X
• OZAMIS CITY, MISAMIS OCCIDENTAL
• MAYOR HILARION RAMIRO SR. REGIONAL
• TRAINING AND TEACHING HOSPITAL
• CAGAYAN DE ORO CITY, MISAMIS ORIENTAL
• NORTHERN MINDANAO MEDICAL CENTER

• Region XI
• TAGUM CITY, DAVAO DEL NORTE
• DAVAO REGIONAL HOSPITAL
• BAJADA, DAVAO CITY
• (JP LAUREL, DAVAO CITY)
• DAVAO MEDICAL CENTER

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List of Medical Centersand Regional Hospitals

• Region XII
• COTABATO CITY, NORTH COTABATO
• COTABATO REGIONAL AND MEDICAL CENTER

• CORDILLERA AUTONOMOUS REGION
• ABATAN, BAUKO, MT. PROVINCE
• LUIS HORA MEMORIAL REG'L. HOSPITAL
• BAGUIO CITY
• BAGUIO GENERAL HOSPITAL AND
• MEDICAL CENTER

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List of Medical Centersand Regional Hospitals

• ARMM
• MARAWI CITY, LANAO DEL SUR
• AMAI PAKPAK MEDICAL CENTER

• CARAGA
• SURIGAO CITY, SURIGAO DEL NORTE
• CARAGA REGIONAL HOSPITAL
• TANDAG, SURIGAO DEL SUR
• ADELA SERRA TY MEMORIAL MEDICAL CENTER

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INFECTION CONTROL in SARS
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Overall Aim of Infection Control Measures in SARS

• Minimize probability of transmission to
  healthcare workers, family and the public

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At a glance Essential Principles of Infection
Control

• Isolation and avoidance of unnecessary contact
• Use of personal protective equipment (PPE) for
  all in close proximity
• Strict personal hygiene
• Masking of patient to reduce respiratory spread

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Public Awareness

• Information is your ally
• Stay informed and keep the public informed
• Check DOH and WHO websites every day

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Current Issues

• Surveillance of Contacts
• Clinical management of SARS
• Managing the peoples response
• Public and travel advisories issued

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Questions that need answers

• infectious agent, mode of transmission
• risk factors for infection (protective factors)
• poor prognosis? Older px , medical comorbidities
• super-spreaders/supertransmitters?
• level of contact required for spread
• infectivity at different stages
• current infection control guidelines enough?
• preparedness of health care systems

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Thank you.