Severe Acute Respiratory Syndrome (SARS)

1. Severe Acute Respiratory Syndrome (SARS) GP seminars

2. SARS Mid November2002 • Guangdong Province, China • “ outbreak of atypical pneumonia” 11 February 2003 • WHO informed • 305 cases (5 deaths) • 30% in health care workers July 2003 • 8,437 probable cases from 32 countries • major foci in China, SE Asia and Toronto • 4 in UK (none from NI)

3. Hasn’t SARS been eliminated? • On 5 July WHO said outbreak was contained. • BUT WHO have warned it might return and urged planning for it. • Majority of experts think it might return. • Planning for it remains a high government priority.

4. Why might it return? • Other new and poorly understood viruses (e.g. Ebola and Marburg) periodically surface to cause outbreaks then disappear again. • This is a respiratory illness – these are usually worse in winter and disappear in summer. • We don’t know how it appeared or where from – so can’t be confident of stopping it from doing so again.

7. SARS coronavirus (SARS CoV) • New member of coronavirus family • found in wild animals in China • incubation period 2-7 (max 10) days • viral shedding peaks 6-10 days after onset of symptoms • droplet spread • less infectious than influenza • no vaccine available

9. SARS CoV - infectivity • Most transmission via close contact with a symptomatic person via large respiratory droplets. Transmission by fomites possible. • Those severely ill more infectious (attack rate of >50% in some hospital staff) • Infectivity increases during second week of illness • Transmission from an asymptomatic person unlikely • May remain infectious up to 10 days once afebrile

11. SARS CoV - infectivity (MMWR 2003:52 (18): 405-11)

12. Lee et al. n=138 Peiris et al. n=50 Donnelly et al. n>1250 Booth et al. n=144 Fever Chills or rigors Cough Myalgia Malaise Runny Nose Sore Throat Shortness of breath Diarrhoea Headache 100 73 57 61 n.a 23 23 n.a 20 56 100 74 62 54 50 24 20 20 10 20 94 65* 50 51 64 25 23 31 27 50 99 28* 69 49 31 2 12 n.a 24 35 Clinical symptoms at presentation (in %) * chills www.sarsreference.com

13. Clinical course - triphasic Week 1 • fever, myalgia, systemic symptoms that improve after a few days Week 2 • Fever returns, oxygen desaturation, CXR worsens Later • 20% get ARDS needing ventilation Peiris - Lancet 2003b; 361: 1767-72

14. SARS - morbidity • Most cases are in healthcare workers caring for SARS patients and close family members of SARS patients • overall mortality 15% • mortality increases with age (> 65 years - 50% mortality) • children seem to develop mild illness

15. Clinical case definition A respiratory illness severe enough for hospitalisation and include a history of: • Fever (> 380C) and • one or more symptoms of respiratory tract illness (cough, difficulty breathing, SOB) and • CXR of lung infiltrates consistent with pneumonia or RDS or PM consistent with pneumonia or RDS without an identifiable cause and • No alternative diagnosis to fully explain the illness CDSC Colindale 15 Aug 03

16. SARS diagnosis • Clinical findings of an atypical pneumonia not attributed to other causes • exposure to suspect/probable SARS • or exposure to their respiratory secretions or body

17. SARS laboratory diagnosis • PCR positive for SARS CoV using validated methods on at least 2 different clinical specimens • Seroconversion (gold standard) (negative antibody test on acute specimen followed by positive test on convalescent sera or > 4 rise in antibody titre between acute and convalescent sera)

18. SARS - treatment • Supportive • avoid aerosol inducing interventions • evidence base for anti-viral drugs lacking • steroids may be helpful

19. NI SARS contingency plan:levels of response 0: initial preparedness (no active cases in UK/Ireland) 1: (A) sporadic imported case(s) to GB/Ireland 1: (B) sporadic imported case(s) to NI 2: intra hospital transmission and/or limited community transmission within definable groups 3: extensive community transmission 4: post outbreak and de-escalation of outbreak response

20. SARS preparedness NI Taskforce and subgroups Clinical Training Port Health Training Acute Primary & Community Care Infection control Human Resources

21. Key points in control of any communicable disease • early case detection • swift isolation • thorough control of infection measures • vigorous identification and management of close contacts by home confinement • public information for those at risk of infection • education of health care professionals

22. Personal protective equipment • Masks • Waterproof long sleeved gowns • Gloves • Goggles • Centrally sourced and distributed

23. Masks and Respirators. • Masks • Main purpose – help prevent particles (droplets) being expelled into environment by wearer • Resistant to fluids – help protect wearer from splashes of blood or other potentially infected substances • Not necessarily designed for filtration efficiency, or to seal tightly to the face • Protection to wearer is therefore limited.

24. Masks and Respirators. • Respirators • Intended to help reduce wearer’s exposure to airborne particles • Made to defined standards • When worn correctly – seal firmly to face – reducing risk of leakage • Some have one way valves – would be useless for putting on infected person

25. What is the correct way to use a mask? First – How not to do it!

26. Could result in serious injury.

27. Could result in suffocation.

28. Could result in serious injury and suffocation!

29. What is the correct way to use a mask? • Should fit snugly over mouth, nose and chin • Coloured side out • Metal strip at top – mould to bridge of nose • If in healthcare setting dispose of as clinical waste • In home – patients should place in plastic bag then in domestic waste • Hands must always be washed following removal. (Remove handling straps only – avoid contact with face part)

30. What is the correct way to use a respirator? • Each type may differ - So always read the accompanying instructions. • Do a fit check or user seal check every time a respirator is put on – Fit is critically important. • It must seal tightly to the face – needs clean-shaven skin – beards, long moustaches and stubble may cause leaks. • Go to a safe area to change it if: breathing becomes difficult; it becomes damage, distorted, or splashed by body fluids; or a proper face fit cannot be maintained.

31. When should masks or respirators be used? • Healthcare workers should use respirators for any contact with suspected or probable cases of SARS • A mask should be used only if a respirator is not available – better than no protection • Patients should use a mask while symptomatic whether in hospital, at home or in transit. • But wearing a mask or respirator is not a guarantee of protection against SARS.

32. Other aspects of infection control • Hand hygiene – essential • Gloves • Fluid resistant long sleeve gown • Eye protection (visor best) • Environmental & equipment decontamination.

33. Putting on PPE • Put on in following order: • Respirator • Eyewear • Gown • Gloves – ensuring wrists of gloves are pulled up over sleeves of gown.

34. Removal of PPE • Crucial that PPE is removed without accidental contamination of facial skin or mucous membranes. • Remove PPE in following order: • Gown • Gloves • Wash hands • Eye protection • Mask • Wash hands

35. Importance of Infection Control Procedures • Detailed aspects of infection control are very important e.g. exactly how to remove a gown, correct hand washing technique etc. • A video describing all this will be produced and widely distributed – Please make sure you and all relevant colleagues watch it. • Correct use of all infection control procedures will provide very good protection against SARS.

36. Likely pathway Sporadic cases • GP - A&E - designated SARS facility Extensive community transmission • Home versus hospital management THIS WILL EVOLVE OVER TIME

37. Scenario 1:Unannounced presentation • Isolate patient • Mask on patient • Assessment – wear your PPE • Case definition/ clinical status • Refer to A&E • Register of staff contacts • Report to public health • Decontamination

38. Scenario 2:Announced (patient at home) • Triage by telephone • Home visit or refer direct to hospital • Refer to A&E • Report to public health • Advise family

39. Implications for primary care Get prepared now! • Develop a practice protocol • Develop a patient pathway (receptionist GP) • Train all staff • Know PPE procedures* • Plan decontamination systems (include nebulisers)* • Identify a dedicated room. Situation has potential to change rapidly!

40. What resources are/ will be available? • Advice on decontamination • Referral algorithms (?designated hospitals) • Training materials • CCDC/ on-call public health • Updated DHSSPS communications • Websites: • www.dhsspsni.gov.uk • www.hpa.org.uk • www.who.int