1. Severe Acute Respiratory Syndrome (SARS)
GP seminars

2. SARS Guangdong Province, China “ outbreak of atypical pneumonia”
Mid November 2002
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.

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 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): )

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

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:

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)
CXR of lung infiltrates consistent with pneumonia or RDS or PM consistent with pneumonia or RDS without an identifiable cause
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)
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 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

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: