Presentation on theme: "Severe Acute Respiratory Syndrome (SARS)"— Presentation transcript:
1 Severe Acute Respiratory Syndrome (SARS) GP seminars
2 SARS Guangdong Province, China “ outbreak of atypical pneumonia” Mid November 2002Guangdong Province, China“ outbreak of atypical pneumonia”11 February 2003WHO informed305 cases (5 deaths)30% in health care workersJuly 20038,437 probable cases from 32 countriesmajor foci in China, SE Asia and Toronto4 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.
5 It is very important that SARS is taken seriously and that we prepare properly for it. It is a moderately infectious disease with a significant mortality rate and no effective treatment or vaccine. Nevertheless by being adequately prepared and taking proper infection control measures we can ensure that we are well protected and any risk is minimised.
6 It is also important to keep things in perspective, compared to many infectious diseases SARS had a small impact. This obviously shouldn’t lead to complacency – without a rigorous worldwide response the situation could have been a lot worse.
7 SARS coronavirus (SARS CoV) New member of coronavirus familyfound in wild animals in Chinaincubation period 2-7 (max 10) daysviral shedding peaks 6-10 days after onset of symptomsdroplet spreadless infectious than influenzano vaccine available
9 SARS CoV - infectivityMost 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 illnessTransmission from an asymptomatic person unlikelyMay remain infectious up to 10 days once afebrile
12 Clinical symptoms at presentation (in %) 9928*694931212n.a24359465*505164252327100746254201073576156FeverChills or rigorsCoughMyalgiaMalaiseRunny NoseSore ThroatShortness of breathDiarrhoeaHeadacheBooth et al. n=144Donnelly et al. n>1250Peiris et al.n=50Lee et al.n=138* chills
13 Clinical course - triphasic Week 1fever, myalgia, systemic symptoms that improve after a few daysWeek 2Fever returns, oxygen desaturation, CXR worsensLater20% get ARDS needing ventilationPeiris - Lancet 2003b; 361:
14 SARS - morbidityMost cases are in healthcare workers caring for SARS patients and close family members of SARS patientsoverall 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)andone or more symptoms of respiratory tract illness (cough, difficulty breathing, SOB)CXR of lung infiltrates consistent with pneumonia or RDS or PM consistent with pneumonia or RDS without an identifiable causeNo alternative diagnosis to fully explain the illnessCDSC Colindale 15 Aug 03
16 SARS diagnosisClinical findings of an atypical pneumonia not attributed to other causesexposure to suspect/probable SARSor 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 specimensSeroconversion (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)The gold standard is seroconversion after 21 days.A negative PCR could mean that no virus was in the sample taken, the PCR was insufficiently sensitiveand.or there was no SARS CoV causing this infection.A positive PCR indicates the person has/had recent SARS infection with SARS CoV and this might have been the cause of SARS in this patient.As viral shedding peaks during second week of symptoms if tests are done too soon may not pick up the virus
18 SARS - treatment Supportive avoid aerosol inducing interventions evidence base for anti-viral drugs lackingsteroids 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/Ireland1: (B) sporadic imported case(s) to NI2: intra hospital transmission and/or limited community transmission within definable groups3: extensive community transmission4: post outbreak and de-escalation of outbreak response
20 SARS preparedness NI Taskforce and subgroups Clinical Training Port HealthTrainingAcutePrimary &Community CareInfectioncontrolHuman Resources
21 Key points in control of any communicable disease early case detectionswift isolationthorough control of infection measuresvigorous identification and management of close contacts by home confinementpublic information for those at risk of infectioneducation of health care professionals
22 Personal protective equipment MasksWaterproof long sleeved gownsGlovesGogglesCentrally sourced and distributed
23 Masks and Respirators. Masks Main purpose – help prevent particles (droplets) being expelled into environment by wearerResistant to fluids – help protect wearer from splashes of blood or other potentially infected substancesNot necessarily designed for filtration efficiency, or to seal tightly to the faceProtection to wearer is therefore limited.
24 Masks and Respirators. Respirators Intended to help reduce wearer’s exposure to airborne particlesMade to defined standardsWhen worn correctly – seal firmly to face – reducing risk of leakageSome 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!
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 chinColoured side outMetal strip at top – mould to bridge of noseIf in healthcare setting dispose of as clinical wasteIn home – patients should place in plastic bag then in domestic wasteHands 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 SARSA mask should be used only if a respirator is not available – better than no protectionPatients 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 – essentialGlovesFluid resistant long sleeve gownEye 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 PPECrucial that PPE is removed without accidental contamination of facial skin or mucous membranes.Remove PPE in following order:GownGlovesWash handsEye protectionMask
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 transmissionHome versus hospital managementTHIS WILL EVOLVE OVER TIME
37 Scenario 1: Unannounced presentation Isolate patientMask on patientAssessment – wear your PPECase definition/ clinical statusRefer to A&ERegister of staff contactsReport to public healthDecontamination
38 Scenario 2: Announced (patient at home) Triage by telephoneHome visit or refer direct to hospitalRefer to A&EReport to public healthAdvise family
39 Implications for primary care Get prepared now!Develop a practice protocolDevelop a patient pathway (receptionist GP)Train all staffKnow 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 decontaminationReferral algorithms (?designated hospitals)Training materialsCCDC/ on-call public healthUpdated DHSSPS communicationsWebsites: