1. Infection Control for SARS Patients Mark Simmerman, RN.MS CDC/NCID/OD International Emerging Infections Program

2. SARS Case Definition Suspect Case Symptoms after 1 November 2002 – Fever (>38°C) AND – Cough or shortness of breath – Diarrhea? Exposure within 10 days of symptoms – Traveling or living in SARS affected area OR – Close contact with SARS case No other explanation for respiratory disease

3. SARS Case Definition Probable Case Suspect case with – Chest x-ray findings of pneumonia or respiratory distress syndrome OR – Autopsy findings of pneumonia or respiratory distress syndrome

4. Close Contact Caring for patient with SARS Living with patient with SARS Contact with respiratory secretions or other bodily fluids of patient with SARS

5. Etiology: Coronavirus Single-stranded enveloped RNA virus Incubation 3-5 days Viremia documented Early evidence suggests 24+ hour survival on dry surface Some patients may shed virus for 30 days from onset of symptoms Reinfection possible

6. Transmission Droplet Direct contact Indirect contact (Fomite) Airborne in health care settings?

7. Risk to Health Care Workers (HCW) HCW and close contacts at highest risk Prince of Wales Hospital, Hong Kong – 62% (85 of 138 patients) of transmission was to HCW and medical students Bumrasnaradul Hospital, Thailand – None of approximately 70 HCWs infected from a single SARS patient who died

8. Goals of SARS Infection Control Early detection Prompt reporting Containment of infection Protection of personnel and environment

9. Management of Possible Cases 1. Immediately isolate patient with symptoms or exposure – Place a mask on the patient 2. Personnel entering the room: – Contact precautions – Airborne precautions

10. How is SARS Spread? Most often by contact and droplet - Touching patient or their secretions and then touching your face - Having droplets from patient ’ s breath, speaking or coughing fall on your hands, face Other possible routes - Airborne (breathing same air without mask)

11. Standard Precautions Frequent hand washing! – Warm water and soap – Alcohol-based hand gel ok Standard personal protective equipment (gloves, mask, eye protection, face shield, gown) Environmental control (patient care equipment, environmental hygiene, linen, trash) Bloodborne pathogen precautions

12. Contact, Droplet, and Airborne Precautions Minimize patient transport Dedicate equipment to patient if possible Clean/disinfect common equipment Use disposable equipment No visitors or non-essential staff Prepare linen on-site using protective equipment Private negative pressure isolation room with anteroom if possible

13. One Example Glass partition Nursing Station and Dressing Area Entrance to anteroom Personal protective equipment & supplies Door to patient room Entrance to hallway Anteroom

14. Negative pressure monitor Patient room

15. Air Circulation Establish negative pressure – Assure clean airflow – Ensure that ventilation and windows do not open to public places – Use fans to direct air flow Test negative pressure – Use tissue paper to test air flow – Assess airflow daily

16. Personal Protective Equipment N-95 or N-100 mask with fit testing Use surgical mask as second layer if mask reused Surgical head cover Goggles or face shield – eyeglasses not adequate Double gown Double gloves Double shoe covers

17. In Dressing Area Put on in this order: – N-95 mask or equivalent !  Ensure good fit – Eye protection essential – Head cover (all hair inside cap) – Surgical mask as outer layer (optional) – Shoe covers – Inner gown (may be cloth) and gloves – Outer gown (disposable) and gloves

18. In Preparation Area Remove in this order: – Outer shoe covers – Outer gown and outer gloves – Head cover – Surgical mask (if used)

19. Outside of Preparation Area Remove in this order: – Inner shoe covers – Inner gown and gloves – Eye protection – N-95 mask Evaluate reusable equipment – Discard damaged or soiled equipment – Clean and disinfect – Label and hang immediately outside anteroom Wash hands vigorously for 2 minutes

20. Basic Principles Minimize time in room Only essential staff Only one patient per room Minimize time within two meters of patient Minimize direct contact with patient Avoid patient ’ s bathroom unless essential Minimize equipment in patient rooms

21. Reducing Droplets Medical management to reduce cough Medical management to reduce vomiting No nebulizer treatments Closed suctioning of ventilated patients Supply oxygen dry- by nasal prongs if possible Patient must wear mask at all times Handle bed linens to avoid creating aerosols

22. High Risk Activities- AVOID When Possible Nebulized treatments Oxygen masks Noninvasive positive pressure ventilation Percussion chest physiotherapy Use of humidified oxygen

23. High Risk Activities – AVOID When Possible (cont ’ d) Manual bagging Tracheal and oropharyngeal suction Nasopharyngeal aspiration/ throat swab Use nasal, not NP swab

24. Intubation for SARS Patients Elective intubation: Paralyze and Sedate! Closed system suctioning HEPA filter or exhaust to outside Avoid manual bagging Negative pressure, well-ventilated room Minimize number of people in room Most experienced staff members only

25. Restrict Access to SARS Ward 1. No visitors 2. No Attendants 3. No students

26. Fomites: Contaminated Surfaces Door knob Bedrail IV Pole Toilet Medical Equipment

27. Clean surfaces 5% NaOCl (Bleach) Sponge Bucket for each room Hot water Clean at least once daily

28. Specimen Handling Single bag specimens in patient ’ s room Double bag outside of patient ’ s room Label and alert laboratory of incoming specimens from SARS-infected patient

29. Surveillance of Health Care Workers Keep lists of SARS case-patients and exposed health care workers Exposed personnel should be followed for fever and respiratory symptoms Health care workers with symptoms should be evaluated & isolated if necessary

30. Follow-up of Discharged Patient Home quarantine for at least 10 days – Temperature log, twice daily – Return if temperature >38°C on two occasions Convalescent serology at 3 weeks after onset of symptoms

31. Conclusion Hand Hygiene: Frequent Washing, Gloving Personal Protective Equipment- Mask+ Eye Protection Always Minimize Contact Time Monitor HCWs for Symptoms Teach and monitor your coworkers!