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SARS in the Emergency Department

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Title: SARS in the Emergency Department


1
SARS in the Emergency Department
  • Aric Storck PGY2
  • Resident Oral Presentation
  • February 12, 2004

2
Outline
  • The anatomy of an outbreak
  • Diagnosis in the Emergency Department
  • The Calgary Health Region

3
SARSa unique disease
  • Dont know where it came from
  • Spread easily between people
  • No vector required
  • No geographical affinity
  • Mimics other diseases
  • Very effective spread in hospital
  • Superspreader phenomenon

4
SARS the EDa unique challenge
  • SARS difficult to recognize early in course of
    illness
  • Early accurate diagnosis critical in preventing
    spread and avoidable mortality

5
the anatomy of an outbreak
6
  • November 19, 2002
  • First reported case Fushan, Guandong
  • November January, 2003
  • Local spread within Guandong
  • February 11, 2003
  • WHO advised of atypical pneumonia
  • 305 sick, 5 dead

7
February 21
  • Doctor from Guangdong checks into ninth floor
    room in Metropole Hotel in Hong Kong
  • Elderly woman from Toronto also stays at same
    hotel

8
February 23
  • Elderly woman returns to Toronto
  • Falls ill shortly after
  • Cared for at home by her son
  • Another guest travels to Vietnam
  • 13 cases subsequently linked to index case at
    Metropole Hotel

9
March 5
March 7
Patient B falls sick and presents to hospital
Patient A dies at home
Source Mcgeer A. The Toronto outbreak. (Accessed
January 31, 2004 at http//www.niaid.nih.gov/sars/
meetings/05_30_03/pdf/mcgeer.pdf
10
March 7, 2003Emergency Department
  • Patient C
  • Rapid atrial fibrillation
  • In bed 1.5 metres away from B
  • Separated by curtain
  • Discharged home after nine hours
  • Patient B presents with respiratory symptoms
  • Received nebulized salbutamol
  • admitted
  • Patient D
  • Pleural effusion/SOB
  • 5 metres away from B
  • Admitted then d/cd home March 10

B,C,D all cared for by same nurse
Source Mcgeer A. The Toronto outbreak. (Accessed
January 31, 2004 at http//www.niaid.nih.gov/sars/
meetings/05_30_03/pdf/mcgeer.pdf
11
  • March 8
  • Patient B transferred to ICU
  • Airborne isolation precautions initiated
    concerned about TB
  • March 10
  • Contact precautions initiated
  • March 12
  • WHO alerts world to severe atypical pneumonia
    (SARS)
  • March 13-14
  • B dies
  • Five family members admitted to three different
    hospitals

12
Back to our atrial fibber
  • Remember .
  • March 7 discharged from ED
  • March 10
  • became febrile
  • March 16
  • To hospital via EMS
  • 9 hours in ED (all isolation precautions used)
  • Cs wife falls ill
  • March 21
  • C dies in ICU

13
Source Mcgeer A. The Toronto outbreak. (Accessed
January 31, 2004 at http//www.niaid.nih.gov/sars/
meetings/05_30_03/pdf/mcgeer.pdf
14
Source Mcgeer A. The Toronto outbreak. (Accessed
January 31, 2004 at http//www.niaid.nih.gov/sars/
meetings/05_30_03/pdf/mcgeer.pdf
15
People C infected
  • Wife
  • Two other family members
  • Two paramedics
  • One firefighter
  • 5 ED staff
  • 2 other hospital staff
  • 2 ED patients
  • 7 visitors to ED
  • ICU MD during intubation
  • Transmitted to one member of family
  • 3 ICU nurses at intubation
  • One family member infected

16
What about the fellow with the pleural effusion?
  • March 13
  • D falls ill Symptoms resemble MI
  • Brought to ED by EMS
  • No precautions initiated
  • Admitted to CCU

17
Source Mcgeer A. The Toronto outbreak. (Accessed
January 31, 2004 at http//www.niaid.nih.gov/sars/
meetings/05_30_03/pdf/mcgeer.pdf
18
  • Patient D
  • Develops renal failure
  • Transferred to another hospital for dialysis

19
Source Mcgeer A. The Toronto outbreak. (Accessed
January 31, 2004 at http//www.niaid.nih.gov/sars/
meetings/05_30_03/pdf/mcgeer.pdf
20
People D infected
  • His wife
  • 1 ED patient
  • 3 ED staff
  • 1 housekeeper
  • 1 physician
  • 2 hospital technologists
  • 2 CCU patients
  • 7 CCU staff
  • 1 paramedic
  • Transmission from those to
  • 6 family members
  • 1 patient
  • 1 medical clinic staff
  • 1 ED nurse

21
(No Transcript)
22
  • 21 ED staff infected
  • 3 prehospital staff

Source CMAJ Aug. 19, 2003
23
November 2002 May 2003the final tally
  • Canada
  • 438 cases
  • 250 probable
  • 188 suspect
  • 375 in Ontario
  • Worldwide
  • 29 countries
  • 8422 cases
  • 908 fatalities

24
Attack Rates
  • Emergency Department Nurses
  • Six 12-hour unprotected shifts where SARS
    exposure possible
  • 22.2 (8/36)
  • 13.6 cases per 1000 nursing hours
  • ICU Nurses
  • 3 unprotected hours
  • 10.3 (4/39)
  • 2.4 cases per 1000 nursing hours
  • CCU Nurses
  • 6 unprotected shifts
  • 60 (6/10)
  • 31.3 cases per 1000 nursing hours

Source CMAJ Aug. 19, 2003
25
So how do we recognize SARS in the Emergency
Department?
26
WHO Case Definition of SARSSuspect CaseRevised
May 1, 2003
  • A person presenting after November 1, 2002 with
    history of
  • high fever (gt38 C)
  • AND
  • cough or breathing difficulty
  • AND one or more of the following exposures during
    the 10 days prior to onset of symptoms
  • close contact with a person who is a suspect or
    probable case of SARS
  • history of travel, to an area with recent local
    transmission of SARS
  • residing in an area with recent local
    transmission of SARS

27
WHO Case Definition of SARS Probable Case
  • A suspect case with radiographic evidence of
    infiltrates consistent with pneumonia or ARDS on
    CXR
  • A suspect case that is positive for SARS
    coronavirus by one or more assays
  • A suspect case with autopsy findings consistent
    with the pathology of RDS without an identifiable
    cause

28
Is the WHO definition useful in the Emergency
Department?
  • Criticisms
  • Based on studies of patients already in hospital
  • Based on common symptoms
  • Difficult to determine contact history
  • How accurate is it?

29
Rainer, et al. Evaluation of WHO criteria for
identifying patients with SARS out of hospital
prospective observational study. BMJ 2003 326
1354-8.
  • Objectives
  • Determine clinical and radiological features of
    SARS
  • Evaluate accuracy of WHO case definition
  • Who
  • 556 hospital staff, patients, relatives who had
    contact with confirmed SARS patient
  • Where
  • SARS screening clinic in ED of tertiary care
    hospital in Hong Kong
  • Outcome
  • Confirmed cases of SARS defined by
  • Known contact with SARS patient
  • Persistent fever (gt38)
  • Evidence of pneumonia
  • Consistent course of illness
  • Did not respond to antibiotics within 48 hours
  • NB serological testing not available at this time

30
(No Transcript)
31
Symptoms more common among patients who did not
develop SARS
  • Cough - 72 vs 64 p0.12
  • Sputum production 29 vs 26 p0.52
  • Sore throat 39 vs 35 p0.53
  • Runny nose 33 vs 26 p0.20

32
Significant findings more common among SARS
patients(plt0.05)
  • Symptoms
  • Fever 81 vs 37
  • Chills 54 vs 21
  • Malaise 34 vs 20
  • Myalgia 27 vs 12
  • Rigor 12 vs 4
  • Neck pain - 3 vs 0.2
  • loss of appetite 5 vs 1
  • SOB 12 vs 7
  • Vomiting 6 vs 2
  • Diarrhea 7 vs 3
  • Signs
  • Higher heart rate
  • Lower sBP
  • Higher temp
  • No difference in RR
  • NB of respiratory symptoms only SOB was
    significant

33
Predictive value of WHO criteria
34
Odds ratios for predicting SARS
  • Fever 12.0 (6.8-21.0)
  • Cough 1.0 (0.6-1.7)
  • SOB 1.5 (0.7-3.5)
  • CXR infiltrate 32.1 (18.0-57.3)

35
Conclusions
  • WHO criteria is based on respiratory symptoms
    which are uncommon in early SARS
  • WHO criteria miss 74 of SARS cases in the
    pre-hospital setting
  • Radiological infiltrates often proceed fever in
    early SARS - thus CXR mandatory for SARS screening

36
Wong W, et al. Accuracy of clinical diagnosis
versus the WHO case definition in the Amoy Garden
SARS cohort. CJEM 20035(6)384-91.
  • Objective
  • Compare WHO case definition with ED physician
    clinical diagnosis
  • Who
  • Retrospective cohort of 818 residents of Amoy
    Gardens presenting to a SARS screening clinic
    during a 2 month outbreak

37
Amoy Gardens
  • Largest community outbreak in world
  • 323 resident cases
  • 37 deaths
  • 18 of all Hong Kong cases
  • Spread linked to
  • Faulty sewage
  • Poor ventilation

38
Outcomes
  • Confirmed SARS
  • Clinical SARS and virological confirmation
  • Undetermined
  • Clinical SARS without virology confirmation (lab
    testing not performed or incomplete)
  • Non-SARS
  • Final diagnosis unrelated to SARS

39
Results
  • SARS 205 cases
  • Undetermined SARS 35 cases
  • Non-SARS 581 cases
  • NB disease prevalence 26 in study population

40
Confirmed SARS (n 205)
Non-SARS (n 581)
No. (and )
No. (and )





Table 2. WHO case definition criteria by final diagnosis Table 2. WHO case definition criteria by final diagnosis Table 2. WHO case definition criteria by final diagnosis Table 2. WHO case definition criteria by final diagnosis Table 2. WHO case definition criteria by final diagnosis
Presenting features  
Presenting features  
Presenting features Yes No Yes No  
 
1. ED temperature gt38 oC 129 (63) 75 (37) 61 (11) 485 (89)  
2. Contact history 187 (91) 18 (9) 466 (81) 112 (19)  
Social 130 (63) NA 390 (84) NA  
Close 28 (14) NA 56 (12) NA  
Clustering 25 (12) NA 12 (3) NA  
Health care worker 4 (2) NA 8 (1) NA  
3. Respiratory symptoms (any) 101 (49) 104 (51) 237 (41) 338 (59)  
Dyspnea 10 (5) 195 (95) 20 (4) 554 (96)  
Cough 95 (46) 110 (54) 223 (39) 352 (61)  
Sputum 19 (9) 185 (91) 53 (9) 522 (91)  
WHO criteria 1, 2 and 3 87 (42) 118 (58) 78 (14) 497 (86)  
Abnormal chest x-ray 177 (86) 24 (14) 66 (20) 258 (80)  
 
Note Column totals may not equal diagnostic group totals because of missing data. Percentages are based on available data.Findings documented at the time of the ED visit.Social contact refers to persons who did not meet criteria for close contact but had contact with a SARS case.Close contact refers to persons who cared for, lived with or had direct contact with respiratory secretions and body fluids of a person with SARS.Clustering refers to an exposure where more than 2 family members were infected with SARS.Health care workers were patients working in private clinics or public hospitals who had contact with SARS cases.Patients with all 3 criteria meet the WHO case definition for suspected SARS.Abnormal chest x-ray was defined as unilateral or bilateral haziness, consolidation, infiltration or ground-glass abnormality on plain posterior-anterior chest x-ray, on presentation. Note Column totals may not equal diagnostic group totals because of missing data. Percentages are based on available data.Findings documented at the time of the ED visit.Social contact refers to persons who did not meet criteria for close contact but had contact with a SARS case.Close contact refers to persons who cared for, lived with or had direct contact with respiratory secretions and body fluids of a person with SARS.Clustering refers to an exposure where more than 2 family members were infected with SARS.Health care workers were patients working in private clinics or public hospitals who had contact with SARS cases.Patients with all 3 criteria meet the WHO case definition for suspected SARS.Abnormal chest x-ray was defined as unilateral or bilateral haziness, consolidation, infiltration or ground-glass abnormality on plain posterior-anterior chest x-ray, on presentation. Note Column totals may not equal diagnostic group totals because of missing data. Percentages are based on available data.Findings documented at the time of the ED visit.Social contact refers to persons who did not meet criteria for close contact but had contact with a SARS case.Close contact refers to persons who cared for, lived with or had direct contact with respiratory secretions and body fluids of a person with SARS.Clustering refers to an exposure where more than 2 family members were infected with SARS.Health care workers were patients working in private clinics or public hospitals who had contact with SARS cases.Patients with all 3 criteria meet the WHO case definition for suspected SARS.Abnormal chest x-ray was defined as unilateral or bilateral haziness, consolidation, infiltration or ground-glass abnormality on plain posterior-anterior chest x-ray, on presentation. Note Column totals may not equal diagnostic group totals because of missing data. Percentages are based on available data.Findings documented at the time of the ED visit.Social contact refers to persons who did not meet criteria for close contact but had contact with a SARS case.Close contact refers to persons who cared for, lived with or had direct contact with respiratory secretions and body fluids of a person with SARS.Clustering refers to an exposure where more than 2 family members were infected with SARS.Health care workers were patients working in private clinics or public hospitals who had contact with SARS cases.Patients with all 3 criteria meet the WHO case definition for suspected SARS.Abnormal chest x-ray was defined as unilateral or bilateral haziness, consolidation, infiltration or ground-glass abnormality on plain posterior-anterior chest x-ray, on presentation. Note Column totals may not equal diagnostic group totals because of missing data. Percentages are based on available data.Findings documented at the time of the ED visit.Social contact refers to persons who did not meet criteria for close contact but had contact with a SARS case.Close contact refers to persons who cared for, lived with or had direct contact with respiratory secretions and body fluids of a person with SARS.Clustering refers to an exposure where more than 2 family members were infected with SARS.Health care workers were patients working in private clinics or public hospitals who had contact with SARS cases.Patients with all 3 criteria meet the WHO case definition for suspected SARS.Abnormal chest x-ray was defined as unilateral or bilateral haziness, consolidation, infiltration or ground-glass abnormality on plain posterior-anterior chest x-ray, on presentation.  
Confirmed SARS (n205)
Non-SARS (n581)

41
Diagnostic accuracy of WHO case definition
Diagnosis by WHO definition Final Diagnosis Confirmed SARS Final Diagnosis Non-SARS Total
SARS 87 78 165
Non-SARS 118 497 615
Total 205 575 780
  • Sensitivity 42.4
  • Specificity 86.4
  • Accuracy 74.9
  • PPV 52.7
  • NPV 80.8
  • NB 6 patients charts incomplete

42
Diagnostic Accuracy of ED diagnosis
ED Diagnosis Final Diagnosis Confirmed SARS Final Diagnosis Non-SARS Total
SARS 186 25 211
Non-SARS 19 556 575
Total 205 581 786
  • Sensitivity 90.7
  • Specificity 95.7
  • Accuracy 94.4
  • PPV 88.2
  • NPV 96.7

43
Conclusions
  • WHO definition would miss 58 of SARS
  • Clinical judgement superior to WHO criteria
  • Caveats
  • Extremely high disease prevalence would affect
    PPV/NPV

44
So if the WHO criteria doesnt work in the ED,
how do I recognize SARS?
45
Wong W, et al. Early clinical predictors of SARS
in the ED. CJEM 20046(1)xx
  • Objectives
  • To assess diagnostic predictors available in the
    ED with final diagnosis of SARS
  • Who
  • Same cohort as previous study

46
Table 2. Univariable association of key predictors for patients with a final diagnosis of severe acute respiratory syndrome (SARS) Table 2. Univariable association of key predictors for patients with a final diagnosis of severe acute respiratory syndrome (SARS) Table 2. Univariable association of key predictors for patients with a final diagnosis of severe acute respiratory syndrome (SARS) Table 2. Univariable association of key predictors for patients with a final diagnosis of severe acute respiratory syndrome (SARS) Table 2. Univariable association of key predictors for patients with a final diagnosis of severe acute respiratory syndrome (SARS) Table 2. Univariable association of key predictors for patients with a final diagnosis of severe acute respiratory syndrome (SARS) Table 2. Univariable association of key predictors for patients with a final diagnosis of severe acute respiratory syndrome (SARS)
Presenting features Confirmed SARS (n 205),no. (and ) Confirmed SARS (n 205),no. (and ) Non-SARS(n 581),no. (and ) Non-SARS(n 581),no. (and ) LR p value  
Presenting features LR p value  
Presenting features Yes No Yes No LR p value  
 
Chills and rigors 91 (44) 114 40 (7) 535 6.4 lt0.000  
Myalgia 85 (41) 120 38 (7) 537 6.3 lt0.000  
Temperature gt38C 129 (63) 75 61 (11) 485 5.7 lt0.000  
Malaise 67 (33) 138 44 (8) 530 4.3 lt0.000  
Abnormal chest x-ray 177 (86) 24 66 (20) 258 4.3 lt0.000  
History of fever 196 (96) 9 195 (34) 380 2.8 lt0.000  
Sore throat 24 (12) 181 102 (18) 472 0.7 0.04  
Abdominal pain 2 (1) 203 24 (4) 550 0.2 0.01  
Headache 31 (15) 174 60 (10) 514 1.5 0.08  
Dyspnea 10 (5) 195 20 (4) 554 1.4 0.39  
Cough 95 (46) 110 223 (39) 352 1.2 0.06  
Sputum 19 (9) 185 53 (9) 522 1.0 0.97  
Nausea 6 (3) 199 19 (4) 556 0.9 0.79  
Vomiting 4 (2) 201 15 (3) 559 0.8 0.59  
Rhinitis 26 (13) 179 102 (18) 473 0.7 0.09  
Diarrhea 6 (3) 199 29 (5) 546 0.6 0.19  
 
Findings documented at the time of the ED visit.LR likelihood ratio.Note Column totals may not equal diagnostic group totals because of missing data. Findings documented at the time of the ED visit.LR likelihood ratio.Note Column totals may not equal diagnostic group totals because of missing data. Findings documented at the time of the ED visit.LR likelihood ratio.Note Column totals may not equal diagnostic group totals because of missing data. Findings documented at the time of the ED visit.LR likelihood ratio.Note Column totals may not equal diagnostic group totals because of missing data. Findings documented at the time of the ED visit.LR likelihood ratio.Note Column totals may not equal diagnostic group totals because of missing data. Findings documented at the time of the ED visit.LR likelihood ratio.Note Column totals may not equal diagnostic group totals because of missing data. Findings documented at the time of the ED visit.LR likelihood ratio.Note Column totals may not equal diagnostic group totals because of missing data.  
47
Table 3. Association of exposure type with final diagnosis Table 3. Association of exposure type with final diagnosis Table 3. Association of exposure type with final diagnosis Table 3. Association of exposure type with final diagnosis
Type of contact Confirmed SARS (n 205),no. (and ) Non-SARS (n 578),no. (and ) LR

None 18 (9) 112 (19) 0.5
Social 130 (63) 390 (67) 0.9
Close 28 (14) 56 (10) 1.4
Clustering 25 (12) 12 (2) 6.0
Health care worker 4 (2.0) 8 (1.4) 1.4

LR likelihood ratioThe p value for linear trend for all types of contact is lt0.000.Social contact refers to persons who did not meet criteria for close contact but had contact with a SARS case.Close contact refers to persons who cared for, lived with or had direct contact with respiratory secretions and body fluids of a person with SARS.Clustering refers to an exposure where more than 2 family members were infected with SARS.Health care workers were patients working in private clinics or public hospitals who had contact with SARS cases.Note column totals may not equal diagnostic group totals because of missing data. LR likelihood ratioThe p value for linear trend for all types of contact is lt0.000.Social contact refers to persons who did not meet criteria for close contact but had contact with a SARS case.Close contact refers to persons who cared for, lived with or had direct contact with respiratory secretions and body fluids of a person with SARS.Clustering refers to an exposure where more than 2 family members were infected with SARS.Health care workers were patients working in private clinics or public hospitals who had contact with SARS cases.Note column totals may not equal diagnostic group totals because of missing data. LR likelihood ratioThe p value for linear trend for all types of contact is lt0.000.Social contact refers to persons who did not meet criteria for close contact but had contact with a SARS case.Close contact refers to persons who cared for, lived with or had direct contact with respiratory secretions and body fluids of a person with SARS.Clustering refers to an exposure where more than 2 family members were infected with SARS.Health care workers were patients working in private clinics or public hospitals who had contact with SARS cases.Note column totals may not equal diagnostic group totals because of missing data. LR likelihood ratioThe p value for linear trend for all types of contact is lt0.000.Social contact refers to persons who did not meet criteria for close contact but had contact with a SARS case.Close contact refers to persons who cared for, lived with or had direct contact with respiratory secretions and body fluids of a person with SARS.Clustering refers to an exposure where more than 2 family members were infected with SARS.Health care workers were patients working in private clinics or public hospitals who had contact with SARS cases.Note column totals may not equal diagnostic group totals because of missing data.
48
Table 4. Complete blood count results by final diagnosis (N 176) Table 4. Complete blood count results by final diagnosis (N 176) Table 4. Complete blood count results by final diagnosis (N 176) Table 4. Complete blood count results by final diagnosis (N 176) Table 4. Complete blood count results by final diagnosis (N 176)
Variable Confirmed SARS (n 71),no. (and ) Non-SARS (n 105),  no. (and ) LR p value

White blood cell count White blood cell count White blood cell count White blood cell count White blood cell count
lt4000 13 (18) 13 (12) 1.5 lt0.000
4000-5999 25 (35) 20 (19) 1.8 lt0.000
6000-7999 23 (32) 21 (20) 1.6 lt0.000
gt8000 10 (14) 51 (49) 0.3 lt0.000
Neutrophil Neutrophil Neutrophil Neutrophil Neutrophil
lt3000 20 (28) 13 (11) 2.5 0.002
3000-3999 16 (23) 21 (18) 1.3 0.002
4000-4999 16 (23) 24 (21) 1.1 0.002
gt5000 19 (26) 56 (49) 0.5 0.002
Lymphocyte Lymphocyte Lymphocyte Lymphocyte Lymphocyte
lt1000 32 (45) 9 (9) 5.0 lt0.000
1000-1499 29 (41) 19 (18) 2.3 lt0.000
1500-1999 7 (10) 32 (30) 0.3 lt0.000
gt2000 3 (4) 45 (43) 0.1 lt0.000
Platelets (103)  Platelets (103)  Platelets (103)  Platelets (103)  Platelets (103) 
lt100 5 (7) 2 (2) 3.5 lt0.000
100-199 49 (69) 22 (21) 3.3 lt0.000
200-299 17 (24) 66 (63) 0.4 lt0.000
gt300 0 (0) 15 (14) 0.0 lt0.000

LR likelihood ratiop values based on linear trend analysis. LR likelihood ratiop values based on linear trend analysis. LR likelihood ratiop values based on linear trend analysis. LR likelihood ratiop values based on linear trend analysis. LR likelihood ratiop values based on linear trend analysis.
49
Table 5. Logistic regression analysis of key predictor variables for all patients (n 786) Table 5. Logistic regression analysis of key predictor variables for all patients (n 786) Table 5. Logistic regression analysis of key predictor variables for all patients (n 786) Table 5. Logistic regression analysis of key predictor variables for all patients (n 786) Table 5. Logistic regression analysis of key predictor variables for all patients (n 786) Table 5. Logistic regression analysis of key predictor variables for all patients (n 786) Table 5. Logistic regression analysis of key predictor variables for all patients (n 786)
Clinical predictor Adjusted OR 95 CI p value Crude OR 95 CI p value

Abnormal chest x-ray 17.4 8.8-34.0 lt0.000 28.8 17.4-47.8 lt0.000
History of fever 9.7 3.6-26.4 lt0.000 42.4 21.3-84.6 lt0.000
Temperature gt38C 6.4 3.2-12.8 lt0.000 13.5 9.2-20.0 lt0.000
Myalgias 5.5 2.6-11.3 lt0.000 10.0 6.5-15.4 lt0.000
Chills 4.0 2.0-8.1 lt0.000 10.7 7.0-16.3 lt0.000
Significant contact 2.6 1.2-5.5 0.01 2.5 1.7-3.8 lt0.000
Diarrhea 0.1 0.08-0.7 0.01 0.6 0.2-1.4 0.21
Malaise 3.8 0.9-10.2 0.06 5.8 3.8-8.9 lt0.000
Headache 1.4 0.6-3.2 0.50 1.5 1.0-2.4 0.07
Nausea 1.4 0.7-3.4 0.82 0.9 0.3-2.2 0.79
Abdominal pain 1.2 0.6-18.2 0.10 0.2 0.01-1.0 0.03
Sore throat 1.0 0.4-2.7 0.93 0.6 0.4-1.0 0.04
Cough 1.0 0.5-1.8 0.93 1.4 1.0-1.9 0.06
Dyspnea 0.9 0.2-3.9 0.89 1.4 0.7-3.1 0.38
Rhinitis 0.7 0.3-1.6 0.37 0.7 0.4-1.1 0.10
Sputum 0.5 0.2-1.5 0.23 1.0 0.6-1.7 0.98
Vomiting 0.5 0.1-1.9 0.62 0.7 0.2-1.4 0.60

OR odds ratio CI confidence intervalAdjusted ORs were determined by controlling for other predictors in the multiple logistic regression model.Crude ORs were derived from univariate analysis without adjustment.Significant contact was defined by either "close contact," "clustering" or "health care worker." See Table 3 for a detailed description of these terms.Note Shaded cells highlight the most powerful statistically significant clinical predictors of a final diagnosis of SARS. OR odds ratio CI confidence intervalAdjusted ORs were determined by controlling for other predictors in the multiple logistic regression model.Crude ORs were derived from univariate analysis without adjustment.Significant contact was defined by either "close contact," "clustering" or "health care worker." See Table 3 for a detailed description of these terms.Note Shaded cells highlight the most powerful statistically significant clinical predictors of a final diagnosis of SARS. OR odds ratio CI confidence intervalAdjusted ORs were determined by controlling for other predictors in the multiple logistic regression model.Crude ORs were derived from univariate analysis without adjustment.Significant contact was defined by either "close contact," "clustering" or "health care worker." See Table 3 for a detailed description of these terms.Note Shaded cells highlight the most powerful statistically significant clinical predictors of a final diagnosis of SARS. OR odds ratio CI confidence intervalAdjusted ORs were determined by controlling for other predictors in the multiple logistic regression model.Crude ORs were derived from univariate analysis without adjustment.Significant contact was defined by either "close contact," "clustering" or "health care worker." See Table 3 for a detailed description of these terms.Note Shaded cells highlight the most powerful statistically significant clinical predictors of a final diagnosis of SARS. OR odds ratio CI confidence intervalAdjusted ORs were determined by controlling for other predictors in the multiple logistic regression model.Crude ORs were derived from univariate analysis without adjustment.Significant contact was defined by either "close contact," "clustering" or "health care worker." See Table 3 for a detailed description of these terms.Note Shaded cells highlight the most powerful statistically significant clinical predictors of a final diagnosis of SARS. OR odds ratio CI confidence intervalAdjusted ORs were determined by controlling for other predictors in the multiple logistic regression model.Crude ORs were derived from univariate analysis without adjustment.Significant contact was defined by either "close contact," "clustering" or "health care worker." See Table 3 for a detailed description of these terms.Note Shaded cells highlight the most powerful statistically significant clinical predictors of a final diagnosis of SARS. OR odds ratio CI confidence intervalAdjusted ORs were determined by controlling for other predictors in the multiple logistic regression model.Crude ORs were derived from univariate analysis without adjustment.Significant contact was defined by either "close contact," "clustering" or "health care worker." See Table 3 for a detailed description of these terms.Note Shaded cells highlight the most powerful statistically significant clinical predictors of a final diagnosis of SARS.
50
Conclusions
  • WHO case definition not sufficiently sensitive or
    specific to guide disposition
  • Positive predictors
  • Fever, lymphopenia, abnormal CXR,
    thrombocytopenia, myalgia, chills
  • Negative predictors
  • Diarrhea
  • Cough and dyspnea not useful predictors in the ED

51
Chen S, et al. Sequential symptomatic analysis in
probable SARS cases. Annals of Emergency Medicine
20044327-33.
  • Objective
  • To determine chronology of symptoms in early SARS
  • Methods
  • Prospective cohort of febrile patients with
    exposure risk presenting to Taipei hospital
  • SARS confirmed by PCR
  • Outcome
  • Clinical symptoms over time in SARS and non-SARS
    cases

52
Results
  • SARS 79
  • Non-SARS - 220

53
Percentage of patients with initial symptoms and
CXR findings
Source Chen et al. Annals of Emerg Med 2004
54
Chronology of symptoms
Sequential symptoms in SARS patients
Sequential symptoms in non-SARS patients
Source Chen et al. Annals of Emerg Med 2004
55
Conclusions
  • Characteristic SARS chronology diarrhea,
    myalgias fever, without coryza or sore throat,
    followed by later LRTI symptoms
  • SARS patients 70 (CI 0.60-0.80)
  • Non-SARS patients 3.2 (CI 0.008-0.05)
  • Cough before fever
  • SARS patients 7.6 (CI 0.02-0.13)
  • Non-SARS patients 51 (CI 0.44-0.58)
  • Sore throat coryza
  • rare in SARS but common in other URTIs

56
  • CXR infiltrate on presentation
  • SARS 75 (0.65-0.85)
  • Non-SARS 10 (0.06-0.14)
  • CXR infiltrate before fever
  • SARS 41 (0.30-0.51)

57
Clinical Featuresnot a typical atypical pneumonia
Source Peiris J, et al. The Severe Acute
Respiratory Syncrome. NEJM 20033492431-41
58
Radiological Findings
  • Initial CXR abnormal in 60-100 of cases
  • Often precedes respiratory symptoms
  • Depends on interval between onset and
    presentation
  • CT abnormal in 67 of patients with initial
    normal CXR
  • Frequent findings
  • Ground class opacities
  • Do not obscure underlying vessels
  • Focal consolidations
  • pneumomediastinum
  • Do not typically have
  • Mediastinal lymphadenopathy
  • Cavitation
  • Pleural effusions

Source Peiris J, et al. The Severe Acute
Respiratory Syncrome. NEJM 20033492431-41
59
Laboratory findings
  • Multiple frequently observed abnormal lab
    findings including
  • Lymphocytopenia
  • Thrombocytopenia
  • Elevated D-dimer
  • Elevated ALT, CK, LDH
  • None distinguish between SARS and other causes of
    pneumonia

60
CAEP. Implications of the SARS outbreak for
Canadian emergency departments.CJEM
20035(5)343-7
  • Emergency departments are the point of first
    contact and the primary destination for the
    sickest patients in the system
  • ED staff evaluate and treat patients before the
    risks and diagnostic possibilities are known

61
  • As the Toronto SARS crisis demonstrated, the
    current practice of housing large numbers of sick
    admitted patients for prolonged times in open,
    densely-populated EDs is a potential public
    health hazard

62
RECOMMENDATIONS
  • Develop national standards for emergency
    department design and operations.
  • Regional resources to be developed to implement
    infection control aspects of ED design and
    operations.
  • Develop relationships and enhance communication
    between public health and the emergency
    community.
  • Eliminate ED overcrowding by ensuring adequate
    long-term and acute-care resources and enforcing
    strict adherence to occupancy limits.
  • Rapid triage assessment of arriving patients by
    appropriately trained nurses at all times should
    be a national standard.

63
SARSin theCalgary Health Region
64
2003 Outbreak
  • 117 patients investigated
  • 1 hospitalized
  • 15 assessed in ED
  • 10 Suspect Cases
  • 1 hospitalized
  • 1 assessed in ED
  • 5 Probable Cases
  • 1 hospitalized
  • 1 assessed in ED

65
Phases of Surveillance
  • Phase 0
  • No SARS cases identified anywhere in the world
  • Family physicians do not have a surveillance role
  • screening required in ED only
  • notification of MOH required if patient admitted
    to hospital
  • Phase 1
  • Cases or outbreaks occuring outside North America
  • family physicians have surveillance role of
    identifying cases in the community
  • ED screening required
  • MOH to be notified of positive screens

66
Phases of Surveillance
  • Phase 2
  • Cases occurring in North America, but not in
    Alberta
  • family physicians have surveillance role of
    identifying cases in community
  • ED screening required
  • notification of MOH if patient screens positive
  • Phase 3
  • Transmission of SARS in a well-defined setting in
    Alberta (e.g. health care facility, households)
  • stand-alone assessment centres operational
  • ED and family physicians have role of telephone
    triage in the community
  • Notification of MOH only if patient seen in ED or
    outpatient office and screens positive

67
Phases of Surveillance
  • Phase 4
  • Community spread within Alberta, not contained
  • stand alone assessment centres operational
  • family physicians have role of telephone triage
    of cases in the community
  • Notification of MOH only if patient seen in ED or
    outpatient office and screens positive
  • Phase 5
  • Widespread disease across Alberta/Canada
  • stand alone assessment centres operational
  • family physicians have role of telephone triage
    of cases in the community
  • Notification of MOH required only if patient is
    seen in office and screens positive

68
Algorithm for Enhanced Surveillance for Severe
Respiratory Illness Phase 0
Client enters ED with fever and respiratory
symptoms
Consider Respiratory Etiquette
Client proceeds to ER waiting Room with fever and
respiratory symptoms
Triage
ED MD assessment
  • Fever gt38, and cough or difficulty breathing
  • AND Positive response to
  • Did you travel to Asia in the 10 days before you
    got sick?
  • OR
  • Did you live with or were in close contact with
    someone who has a similar illness and who
    traveled to Asia in the 10 days before they
    became sick?
  • OR
  • Are you a health care worker in the CHR?
  • AND radiographic infiltrates consistent with
    pneumonia or ARDS
  • AND clinical condition warrants admission to
    hospital

69
No
Yes
  • Arrange for admission, continue isolation, use
    droplet precautions
  • Complete SRI Form 2 for ED Staff contact
    follow-up (if required)

Treat as clinically indicated No further action
  • Admit to an inpatient isolation room or negative
    pressure room
  • Continue droplet precautions
  • Notify infection control
  • Initiate Rule out lab testing

ED MD to notify MOH of case under Investigation
(CUI)
70
Health CanadaInfection Control
GuidelinesNon-outbreak setting
  • Screening questions asked gt1 metre from patient
  • Fever or Respiratory Symptoms?
  • Travel to Asia past 2 weeks?
  • Contact with somebody who travelled to Asia past
    2 weeks?
  • Health care worker?
  • If Yes to Q1 and one of Q2-Q4
  • HCW should don surgical mask and eye protection
  • Patient should don surgical mask and hand hygiene
  • Patient should be moved to separate area
  • Persons with patient should don surgical mask

71
Algorithm for Enhanced Surveillance for Severe
Respiratory Illness Phase 1 2
Client enters ED with fever and respiratory
symptoms
Triage to institute SARS infection
control procedures
  • Fever gt38, and cough or difficulty breathing
  • AND Positive response to
  • Did you travel to zone of emergencce in the 10
    days before you got sick?
  • OR
  • Did you live with or were in close contact with
    someone who has a similar illness and who
    traveled to the zone of emergence in the 10 days
    before they became sick?
  • OR
  • Are you a health care worker in the CHR?
  • OR
  • Have you handled live SARS-CoV in a lab?

72
Radiologic evidence consistent with pneumonia or
ARDS
No
Yes
  • Classify as suspect case
  • report to MOH
  • treat as clinically indicated

Clinical condition warrants admission
73
Yes
No
  • Isolation and infection control
  • complete SRI Form 2 for
  • ED staff contacts
  • ED to fax Form 2 to PH
  • initiate R/O lab testing
  • Arrange for admission
  • continue infection control
  • complete SRI forms 1 2
  • initiate R/O lab testing
  • negative pressure room

74
Health CanadaInfection Control
GuidelinesOutbreak setting
  • Screening questions asked gt1 metre from patient
  • Fever or Respiratory Symptoms?
  • If yes to Q1 don N95 mask and eye protection,
    isolate patient, patient to don surgical mask,
    then ask
  • Travel to SARS-affected area in past 2 weeks?
  • Contact with somebody who traveled to this area
    past 2 weeks?
  • Health care worker?
  • Been to SARS affected hospital
  • If Yes to one of Q2-Q4
  • Immediately notify infection control

75
Surveillance Algorithmcomments
  • Based on WHO case definition
  • Phase 0 only screens the sickest patients
  • Should phases of surveillance be redefined?
  • Eg Phase 0 to include isolated contained cases

76
Our Emergency Departments
  • Negative pressure rooms
  • SARS supplies
  • Surgical masks
  • N95 masks
  • Gowns
  • Gloves
  • PAPRs
  • Rule out lab kit

77
SARSthe present
78
SARS Update
  • September 2003
  • Medical researcher in Singapore
  • December 16, 2003 - present
  • 3 confirmed cases
  • 1 probable case
  • All in southern China
  • No epidemiological link between cases

79
SARSthe future
80
???
81
  • Where did SARS come from?
  • Is it still there?

82
Animal Reservoirs?
  • Early cases included restaurant and market
    workers who handled exotic meats
  • Virus very similar to SARS-CoV cultured from palm
    civets and raccoon dogs
  • SARS-CoV now found in domestic cats and ferrets
  • Definitive animal reservoir not yet identified

Himalayan palm civet
Raccoon dog
83
  • How is it transmitted?
  • Aerosol vs droplet
  • Are N95 masks really necessary
  • Breakthrough cases in full PPE
  • Superspreaders?

84
The fact that SARS was contained less than four
months after the first global alert, despite the
absence of a vaccine, effective treatment, or
reliable point-of-care diagnostic test, is a
triumph of public health and a tribute to the
power of political commitment.
WHO November 2003
85
the end
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