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SARS: Overview and Healthcare Preparedness

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Title: SARS: Overview and Healthcare Preparedness


1
SARS Overview and Healthcare Preparedness
  • Arjun Srinivasan, MD
  • Division of Healthcare Quality Promotion
  • asrinivasan_at_cdc.gov

2
SARS A brief history
  • February 14, 2003-
  • Report of 305 cases of unexplained pneumonia in
    Guangdong Province, China.
  • February 21, 2003-
  • A 65 year old doctor from Guangdong checks into
    room 911 of the Metropole hotel in Hong Kong

3
Spread from the Hotel M in Hong Kong
Guangdong Province, China
A
A
Hotel MHong Kong
4
SARS A brief history
  • February 28th- March 15, 2003-
  • Reports of unexplained pneumonia in Vietnam,
    Singapore and Canada.
  • More than 50 healthcare workers in the Prince of
    Wales hospital in Hong Kong come down with an
    unexplained respiratory illness.
  • The syndrome is named severe acute respiratory
    syndrome

5
SARS A brief history
  • March 17, 2003
  • WHO asks 11 labs in 9 countries to form a network
    to discover the etiology of SARS.
  • All samples are shared between the labs and any
    information discovered is posted immediately on a
    secure site and instantly available to all the
    others.

6
SARS A brief history
  • March 24, 2003-
  • Investigators in Hong Kong and at CDC announce
    novel coronavirus is possible cause of SARS.
  • April 8-12, 2003-
  • Coronavirus etiology is confirmed by other
    researchers and the sequence of the virus is
    published.

7
SARS A brief history
  • April 16, 2003-
  • Investigators in the Netherlands fulfill Kochs
    postulates to prove definitively that SARS
    coronavirus (SARS Co-V) is the cause of SARS.

8
Identification of a Novel Coronavirus in Patients
with Severe Acute Respiratory Syndrome
A Major Outbreak of Severe Acute Respiratory
Syndrome in Hong Kong
9
SARS A brief history
  • May 31, 2003-
  • Outbreak controlled in Singapore.
  • June, 2003
  • Outbreaks controlled in Taiwan, Hong Kong, Canada
    and China.
  • July 5, 2003
  • WHO declares outbreak contained worldwide.

10
Global SARS Outbreak
Reported to WHO, November 1, 2002- July 11, 2003
11
Other outcomes
  • Tens of thousands of people quarantined.
  • Impact of hospital closures and delays of
    elective procedures.
  • More than 60 billion dollars lost in Asia alone.
  • Massive fear and panic.

12
Empty jewelry showcases from Hong Kong and
Singapore Zurich Trade Fair
13
Caronaviruses
  • Cause severe disease and death in animals.
  • In humans, caronaviruses were mostly associated
    with mild respiratory illness, with very rare
    reports of more serious infections.

14
Caronaviruses
PEDV
I
TGEV
CCoV
FIPV
HCoV-229E
100
III
IBV-Avian
68
TCoV
100
100
MHV
SARS
Rat-SDAV
II
HEV
HCoV-OC43
BCoV
10 nt
15
Epidemiology and Transmission
16
Person to Person Spread
Probable cases of SARS by reported source of
infection, Singapore, Feb 25 Apr 30
17
Transmission during aerosol-generating procedures
  • Toronto, Canada, April 2003
  • 9 HCWs infected following difficult intubation of
    a critically ill SARS patient.
  • All HCWs reported wearing recommended protective
    equipment.

18
Transmission characteristics
  • On average, each SARS patient infected 3 other
    people.
  • This rate of infectivity (R0) is most consistent
    with a disease spread by direct contact or large
    droplets, not light, airborne particles (WHO
    consensus report).

19
BUT . . .
  • Aerosol generating medical procedures and other
    acts that generate aerosols (e.g. surface
    cleaning) may increase risk of transmission.
  • Risk from stool and fomites remains unclear.

20
Average number of secondary cases from
un-isolated patients
21
Total SARS Cases and Healthcare Workers by
Location
Total No. SARS cases
HCW
HCW
22
Percentages who acquired SARS in healthcare
facilities
23
Clinical Features
24
Initial clinical features
  • Incubation period 1-10 days
  • Median 4-7
  • Rarely up to 14 days
  • Initial symptoms fever, chills/rigors, headache,
    myalgias, malaise
  • Diarrhea has been a prominent feature of early
    illness in some

25
Initial respiratory symptoms
  • Respiratory symptoms often begin 3-7 days after
    symptom onset, peak in second week
  • Fever may resolve prior to respiratory symptoms
  • 30 have respiratory symptoms at onset

26
Symptoms Commonly Reported
27
Clinical Findings
28
Chest radiographs
  • Chest X-ray infiltrates develop in nearly 100 of
    laboratory confirmed cases
  • 66 abnormal by day 3
  • 97 abnormal by day 7
  • 100 abnormal by day 10

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.
29
Radiographic Features of SARS
  • Infiltrates
  • initially focal, often peripheral lower lobes
  • interstitial
  • 75 progress to involve multiple lobes or both
    lungs
  • High resolution computed tomography more
    sensitive
  • Ground glass opacification
  • Peripheral lower lobes

30
Case fatality rate by age group- Hong Kong
31
Patients requiring mechanical ventilation
1. Unpublished data, CDC. 2. Booth CM SM, et al.
JAMA 5/6/03. 3. Tsang KW, et al. NEJM. 3/31/03 4.
Peiris JSM, et al. Lancet 4/8/03 5. Lee N. et al
NEJM 4/7/03
32
SARS Laboratory Diagnostics
33
Available tests for SARS
  • Polymerase chain reaction (PCR)
  • Most rapid test
  • Have been problems with false positive and false
    negative results.
  • Serology (antibody assay)
  • Appears quite reliable
  • Results may take up to 28 days

34
Beware of lab tests!
  • A test is limited by the quality of the specimen-
    especially an issue with respiratory specimens.
  • The predictive value of any test is ultimately
    determined by the prevalence of the disease.

35
Effect of disease prevalence on Positive
Predictive Value (PPV)
Sensitivity of test 50 Specificity of test
95
Prevalence 50 PPV 95
PPV
Prevalence 1 PPV 9
Prevalence of SARS among persons tested
36
SARS PCR
  • Reasons for false negative results
  • low titer virus in respiratory secretions in
    first few days after onset of illness
  • Reasons for false positive results
  • contamination from previously amplified DNA
  • cross-contamination between specimens

37
SARS PCR- confirmation of results
  • Given challenges with testing, positive results
    must be confirmed, preferably in another lab
    using the original sample.
  • Preferable to also test specimens from at least 2
    sites OR from the same site on different days.

38
SARS Serology
  • Current enzyme immunoassay appears to be highly
    specific
  • No cross reactions with other CoV
  • No false positives in normal blood donors
  • Can be positive in as few as 8 to 10 days.
  • Not definitively negative until day 28.

39
What to test
  • Respiratory specimens
  • sputum gt aspirates gt NP/OP washes gt NP/OP swabs
  • Blood
  • Stool
  • Multiple samples and larger quantities are better!

40
When to test
41
Peiris et al Lancet, May 24, 2003
42
Peiris personal communication
43
The future of SARSAn enigma shrouded in mystery
44
Will SARS be back?
  • Un-known, but there are potential reservoirs for
    re-emergence
  • From original animal reservoir
  • Unrecognized transmission in humans
  • Persistent infection in humans
  • Labs
  • Most likely to re-emerge outside the US.

45
Future treatment options
  • Potential therapies requiring further
    investigation
  • Cystine proteinase inhibitors
  • Interferons
  • Immunomodulatory agents
  • Corticosteriods
  • SARS-CoV specific immune globolin
  • Others?

46
Future prevention options
  • Research is under way to develop a vaccine.
  • Availability of animal coronavirus vaccines is
    encouraging.
  • Unclear how applicable that experience will be to
    SARS vaccine development.

47
SARS preparedness and response planningAn ounce
of prevention
48
SARS preparedness planning
  • We must take advantage of what was learned to
    prepare for future outbreaks.
  • SARS preparedness and response planning can both
    build on and enhance planning for bioterrorism
    and other emerging infections.

49
CDC approach to SARS planning
  • SARS task force assembled to address several
    aspects of preparedness and response planning.

50
CDC approach to SARS planning
  • Draft plans developed and input solicited from
    members of over 20 partner societies representing
    public health, healthcare workers and healthcare
    administration.
  • Conference calls.
  • Face-to-face meetings.

51
Key objectives
  • Rapid identification of SARS cases.
  • Early implementation of control measures.
  • Efficient communication and co-operation between
    healthcare, the public and public health.

52
SARS plan-Core document/summary and supplements
  • A Command and control issues
  • B Surveillance
  • C Healthcare facilities
  • D Community containment
  • E International travel
  • F Laboratory diagnosis
  • G Communication

53
The devil is in the details!
  • The supplements provide specific guidance in the
    various areas.
  • Suggestions are divided into basic and enhanced
    measures to allow for escalation as an outbreak
    progresses.

54
Preparedness and Response in Healthcare Facilities
55
Lessons learned for healthcare
  • Healthcare facilities were critical areas in the
    2003 outbreak.
  • They were essential in controlling the outbreak,
    despite being among the hardest hit by it.

56
Lessons learned for healthcare
  • SARS stretched healthcare resources to their
    limits.
  • Preparedness planning will be essential to
    limiting the impact of any future outbreaks.

57
Key objectives for healthcare facilities
  • Multi-disciplinary plan to address a potential
    outbreak.
  • Early identification of cases.
  • Rapid and effective isolation of cases.
  • Implementation of effective infection control
    measures.

58
Key objectives for healthcare facilities
  • Ability to manage a small number of SARS patients
    without disrupting delivery of care.
  • Good communication with HCWs, community and
    public health.

59
Development of a SARS plan
  • Given the range of issues involved, and the speed
    and complexity of the required response,
    facilities should consider developing a formal
    SARS preparedness and response plan.
  • This plan may simply be an addition to existing
    bio-terrorism or emergency response plans.

60
SARS planning committee
  • Designated person to co-ordinate an outbreak
    response and chair a planning committee.
  • Multi-disciplinary planning committee with
    representation from all groups potentially
    affected by SARS, e.g.
  • Medical, nursing, laboratory and support staff.
  • Administration.
  • Infection control

61
SARS planning committee
  • Other groups may need to be adjunct members to
    consider certain issues, e.g.
  • Labor and unions
  • Mental health
  • Directors of training/teaching programs

62
Key issues to consider
  • Surveillance
  • Clinical evaluation
  • Infection control measures
  • Patient isolation
  • Engineering controls
  • Exposure evaluation
  • Staffing needs and personnel policies
  • Access controls
  • Supplies and equipment
  • Communication

63
SARS surveillance- The backbone of response
  • Early diagnosis and detection can prevent further
    transmission, while missed cases can lead to
    large outbreaks.
  • Healthcare facilities will play a crucial role in
    surveillance.
  • Surveillance activities must expand as SARS
    activity escalates.

64
Surveillance in the absence of SARS
  • Challenges-
  • How to catch early cases given that SARS is
    extremely unlikely and the presentation is
    non-specific.
  • How to screen with no epidemiologic links.
  • Less of an issue in the US since SARS will
    probably re-emerge elsewhere.

65
Surveillance in the absence of SARS
  • Will need to rely on known risk factors for SARS
  • Travel to previously affected areas
  • Contact with healthcare facilities
  • Contact with other patients with unexplained
    pneumonia.

66
Surveillance recommendations
  • Ask all patients hospitalized with unexplained
    pneumonia about the known risks.
  • Report cases to the health department to aid
    recognition of clusters of unexplained pneumonia.
  • Consider SARS testing in consultation with public
    health representatives.

67
Surveillance in the presence of SARS
  • If SARS comes back, surveillance must expand.
  • Screen all patients with fever or respiratory
    symptoms (not just those admitted) for known
    risks, especially travel to areas where SARS is
    active OR contact with a SARS patient.

68
Clinical evaluation
  • In the absence of SARS activity in the world,
    patients with pneumonia should be evaluated as
    usual, with addition of screening questions for
    SARS risks.
  • In the presence of SARS activity, the SARS
    clinical algorithm can help guide evaluation in
    patients who have SARS risk factors.

69
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 and notify Health Department2
- CXR
CXR
No Radiographic Evidence of Pneumonia
Radiographic Evidence Of Pneumonia
No Alternative Diagnosis
Alternative diagnosis confirmed3
Perform SARS testing
Continue SARS isolation and re-evaluate 72 hours
after initial evaluation
Symptoms improve or resolve
Consider D/C SARS isolation precautions5
Laboratory evidence of SARS-CoV or No
alternative diagnosis
Alternative diagnosis confirmed3
Persistent fever or unresolving respiratory
symptoms
  • Perform SARS test
  • Continue SARS isolation for additional
  • 72 hours. At the end of the 72
  • hours, repeat clinical evaluation
  • including CXR

Continue SARS isolation until 10 days following
resolution of fever given respiratory symptoms
are absent or resolving
Consider D/C SARS isolation precautions5
CXR
No radiogrpahic evidence of pneumonia
Consider D/C SARS isolation precautions5
70
Clinical evaluation
  • Ensure that staff who will evaluate potential
    SARS cases have access to and appropriate
    training with personal protective equipment.

71
Infection control measures
  • Make sure HCWs understand the importance of basic
    infection control practices like isolation and
    hand hygiene (whether there is SARS or not!).
  • Ensure that HCWs have access to and training
    with, personal protective equipment.

72
Infection control measures
  • Consider adopting a universal, respiratory
    hygiene/cough etiquette strategy.
  • Common and important pathogens are transmitted by
    respiratory secretions influenza, pertussis,
    mycoplasma.
  • Controlling respiratory secretions can help
    reduce transmission.

73
Respiratory hygiene/ Cough etiquette
  • Encourage patients to alert staff if they are
    suffering febrile respiratory illness.
  • Give patients a surgical mask to wear or tissues
    to cover their noses and mouths.
  • Encourage patients to practice hand hygiene after
    touching their faces.

74
Respiratory hygiene/ Cough etiquette
  • Separate patients with febrile respiratory
    illness from other patients in the waiting area.
  • Manage patients using droplet precautions until
    it is determined the cause of the respiratory
    illness is a pathogen that does not require
    precautions.

75
Patient isolation
  • Though most transmission appears to occur from
    infectious droplets, there are infrequent
    episodes where airborne transmission cannot be
    excluded.
  • For now, CDC continues recommend that SARS
    patients be managed with airborne PLUS contact
    precautions.

76
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.

77
Patient cohorting
  • Some facilities have few (or no) negative
    pressure rooms.
  • Facilities will need to decide at what point they
    will choose to cohort patients onto a SARS unit
    in private, but non-negative pressure, rooms.

78
Advantages of a SARS unit
  • Focuses SARS related resources in one area.
  • Physically separates SARS patients from others.
  • Was an effective strategy in parts Toronto and
    Taiwan.

79
Engineering controls
  • Determine capacity for airborne isolation in both
    the ICU and non-ICU settings.
  • Determine how a SARS unit might be created
  • Can any nursing unit be made negative pressure to
    surroundings?
  • Can rooms on any unit be converted to negative
    pressure?

80
Engineering controls
  • Identify a space that might serve as a SARS
    evaluation center in the event of a larger
    outbreak.
  • Determine how best to get patients to and from
    the evaluation center.

81
Exposure reporting and evaluation
  • Surveillance of exposures may help with early
    case identification.
  • Develop a mechanism for reporting and follow-up
    of exposed HCWs.

82
Exposure reporting and evaluation
  • Perform symptom surveillance for fever or
    respiratory symptoms in HCWs with unprotected
    exposures.
  • Consider furlough of HCWs with unprotected
    high-risk exposures (i.e. during respiratory
    procedures).
  • Evaluate symptomatic HCWs with the SARS clinical
    algorithm.

83
Staffing needs
  • SARS posed a unique challenge for staffing needs
    with increased demands but diminished
    availability of HCWs due to illness and furlough.

84
Staffing issues
  • Determine staffing needs for varying numbers of
    SARS patients.
  • Consider designating teams to provide initial
    care in an outbreak
  • General, multi-disciplinary care team
  • Emergency care/ ICU team
  • Respiratory procedures team
  • Consider how teams could be expanded.

85
Staffing issues
  • Caring for SARS patients is emotionally and
    physically draining for HCWs, especially with
    prolonged respirator wear.
  • Staffing may have to be increased to allow HCWs
    to have PPE free time.

86
Home/work quarantine
  • To ensure adequate staff in facilities in
    Toronto, some exposed HCWs were placed on
    home/work quarantine.
  • They were only allowed to travel back and forth
    to work, but were otherwise required to stay
    home.
  • This might be needed if an outbreak become large.

87
Personnel policies
  • A variety of issues to consider
  • What will be the criteria for furlough?
  • Will furlough be paid or unpaid?
  • How will exposure evaluations and follow-up be
    done?
  • What assistance can the facility provide to HCWs
    on home/work quarantine?
  • What mental health assistance can be provided to
    help HCWs deal with the stress of an outbreak?

88
Facility Access Controls
  • During an outbreak, careful screening of
    entrants, combined with access controls to the
    facility can help keep unrecognized cases from
    entering.

89
Access controls
  • Facilities will also need to establish criteria
    to limit visitors, especially to SARS patients.
  • Criteria for limiting elective procedures and
    even new admissions may be needed in a large
    outbreak.

90
Supplies and Equipment
  • Determine the current availability of and
    anticipated need for supplies that might be
    needed in an outbreak
  • Personal protective equipment and hand hygiene
    supplies.
  • Ventilators
  • Consider what back up plans are in place if
    supplies are limited.

91
Communication
  • Clear and quick communication with the health
    department, facility staff and public will be
    crucial to manage the outbreak and control panic.

92
Health Departments
  • Establish a mechanism to share information with
    the health department
  • SARS activity in the community
  • SARS activity in the facility
  • Exposures, for contact tracing
  • Information on SARS patients about to be
    discharged for community isolation

93
Staff and Public
  • Determine ways to update people on SARS activity
    in the hospital, what control measures are being
    taken and what they may be asked to do (e.g.
    entry screening etc).
  • Co-ordinate information release with health
    department so messages are consistent.

94
Broader Healthcare System Issues
  • A large SARS outbreak will generate resource
    needs that must be addressed at a larger level
    than one facility
  • Funding for furlough, lost revenue
  • Supply shortages
  • Staff shortages
  • Regulatory issues

95
Conclusions
  • SARS poses a major challenge to healthcare
    facilities and staff.
  • Healthcare workers around the world demonstrated
    enormous courage to meet that challenge last
    year.

96
Conclusions
  • Facilities can help by developing plans to manage
    SARS (and other infectious emergencies) in
    advance.
  • Facilities should be prepared to move swiftly
    and boldly to implement aggressive control
    measures.

97
CDC SARS Preparedness Planhttp//www.cdc.gov/nc
idod/sars/sarsprepplan.htm
  • Thank you!
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