Prof. Ossama Rasslan Secretary general, ESIC Directory, IFIC Issued 7 th May 2003

A New Disease Called SARS SARS “Severe Acute Respiratory Syndrome” SARS “Severe Acute Respiratory Syndrome” SARS is an atypical pneumonia, caused by aSARS is an atypical pneumonia, caused by a virus unidentified before. virus unidentified before. SARS was recognized in several countriesSARS was recognized in several countries of the world particularly south east of Asia. of the world particularly south east of Asia. Till now, reservoir seems to beTill now, reservoir seems to be symptomatic human cases only. symptomatic human cases only. There is No evidence of asymptomaticThere is No evidence of asymptomatic healthy carriers. healthy carriers.

November 16, 2002 The first case of SARS involved a man, in southern China's This man was a "super-infector" who subsequently infected four others.November 16, 2002 The first case of SARS involved a man, in southern China's This man was a "super-infector" who subsequently infected four others. November 31, 2002 Deadly outbreak of atypical pneumonia carries on in China, & killed at least 34 people.November 31, 2002 Deadly outbreak of atypical pneumonia carries on in China, & killed at least 34 people. December 30, 2002 Guangdong province had reported at least 300 cases.December 30, 2002 Guangdong province had reported at least 300 cases. January 2003 A salesman carries SARS to Guangzhou. It spreads through three hospitals in the city, where Dr. Liu Jianlun, helped to treat the victims.January 2003 A salesman carries SARS to Guangzhou. It spreads through three hospitals in the city, where Dr. Liu Jianlun, helped to treat the victims. “SARS” HISTORY

February 15, 2003 Dr. Liu fell ill, probably catching the virus from a patient in the province.February 15, 2003 Dr. Liu fell ill, probably catching the virus from a patient in the province. February 21, 2003 Dr Liu, visiting Hong Kong's Metropole Hotel.February 21, 2003 Dr Liu, visiting Hong Kong's Metropole Hotel. He spread the virus to The hotel guests,whom in turn carried the disease across Asia and to North America and Europe. He spread the virus to The hotel guests,whom in turn carried the disease across Asia and to North America and Europe. February 22, 2003 Dr Liu was admitted to the Hospital, and died days later.February 22, 2003 Dr Liu was admitted to the Hospital, and died days later. “SARS” HISTORY “cont.”

February 25, 2003 Three other Metropole guests,leaving the hotel, were infected with the virus, then hospitalized in Singapore and were recovering. However, many others in Singapore became infected, including a doctor who treated them. March 5, 2003 A 78-year-old Canadian woman, Kwan Sui-chu, who were leaving Hong Kong's Metropole Hotel, died in hospital in TorontoMarch 5, 2003 A 78-year-old Canadian woman, Kwan Sui-chu, who were leaving Hong Kong's Metropole Hotel, died in hospital in Toronto “SARS” HISTORY “cont.”

March 12, 2003 The World Health Organization issues a global SARS alert March 16, 2003 WHO put out a rare travel advisory ;calling SARS a global threat. More than 215 cases outside China had already been reported March 16, 2003 WHO put out a rare travel advisory ;calling SARS a global threat. More than 215 cases outside China had already been reported. “SARS” HISTORY “SARS” HISTORY “cont.”

March 19, out of the 145 SARS patients in Hong Kong had died. March 21, 2003 A 76-year-old Canadian man dies of SARS at Scarborough Grace Hospital in Toronto. March 25, 2003 The Toronto Hospital closed its doors to new patients and most visitors. On the same day, provincial health officials announced the quarantine of the health workers' families. “SARS” HISTORY “cont.”

March 27, 2003 WHO asked airlines to screen passengers for SARS on flights leaving affected areas. March 29, 2003 Dr. Carlos Urbani, discoverer of the SARS virus in Vietnam, died in Hanoi. “SARS” HISTORY “cont.” May 6, Cases Deaths Deaths 475

The primary way of spread is by droplet transmission.The primary way of spread is by droplet transmission. This can happen when someone who is sick coughs or sneezes onto other people, or nearby surfaces.This can happen when someone who is sick coughs or sneezes onto other people, or nearby surfaces. Most cases have involved people who cared for or lived with someone with SARS, or had direct contact with infectious material (as respiratory secretions) from a diseased person.Most cases have involved people who cared for or lived with someone with SARS, or had direct contact with infectious material (as respiratory secretions) from a diseased person. How SARS Spreads

Potential ways of spread include touching the skin of other people or objects that are contaminated with infectious droplets and then touching eye(s), nose, or mouth.Potential ways of spread include touching the skin of other people or objects that are contaminated with infectious droplets and then touching eye(s), nose, or mouth. All age and sex groups are susceptible.All age and sex groups are susceptible. No evidence that during incubation period or asymptomatic prodroma, transmission have occurred.No evidence that during incubation period or asymptomatic prodroma, transmission have occurred. Symptomatic and very ill cases seem to be the most infectious.Symptomatic and very ill cases seem to be the most infectious. How SARS Spreads “cont.”

The WHO on April 16, announced that the new SARS virus is a coronavirus.The WHO on April 16, announced that the new SARS virus is a coronavirus. The WHO have concluded the coronavirus meets all four of "Koch's postulates" for a causative agent, namely;The WHO have concluded the coronavirus meets all four of "Koch's postulates" for a causative agent, namely; 1-It must be found in all cases of the disease, 2-It must be isolated from the host and grown in pure culture, 3-It must reproduce the original disease when introduced into a susceptible host, and 4-It must be found in the experimental host so infected. Coronaviruses - the cause of SARS

Coronavirus particles are irregularly-shaped, ~60-220nm in diameter, with an outer envelopeCoronavirus particles are irregularly-shaped, ~60-220nm in diameter, with an outer envelope The name coronavirus referes to the protein molecules surrounding the virus making it crown-like, (corona “Latin” =crown).The name coronavirus referes to the protein molecules surrounding the virus making it crown-like, (corona “Latin” =crown). Able to survive in dry air for up to 3 hours (? 24 h).Able to survive in dry air for up to 3 hours (? 24 h). Can be killed by exposure to UV light, so they will not survive under sunlight.Can be killed by exposure to UV light, so they will not survive under sunlight. Mutate easily, and each mutation triggers off an epidemic of respiratory disease.Mutate easily, and each mutation triggers off an epidemic of respiratory disease. Coronaviruses “ cont.” Coronaviruses “ cont.”

The envelope carries three proteins:The envelope carries three proteins: S - Spike glycoprotein: receptor binding, cell fusion, major antigen. E - Envelope protein: small, envelope-associated protein. M - Membrane protein: transmembrane - budding, envelope formation. In a few types, there is a fourth protein: HE - Haemagglutinin-esterase. The genome is associated with a basic phosphoprotein (N).The genome is associated with a basic phosphoprotein (N). Coronaviruses “ cont.” Coronaviruses “ cont.”

Coronaviruses replication Coronaviruses replication

On April 14, CDC has sequenced the genome for the SARS virus (Non-segmented, single-stranded, “+ve”sense RNA) On April 14, CDC has sequenced the genome for the SARS virus (Non-segmented, single-stranded, “+ve”sense RNA) The sequence data confirm that the SARS coronavirus is a previously unrecognized coronavirus.The sequence data confirm that the SARS coronavirus is a previously unrecognized coronavirus. The genome of the SARS virus is 29,727 nucleotides in length.The genome of the SARS virus is 29,727 nucleotides in length. Envelope proteins (S), (E), (M) and (N) have been identified.Envelope proteins (S), (E), (M) and (N) have been identified. SARS Virus, sequencing

After the virus enters the body it requires 3-10 days incubation period before the disease appears.After the virus enters the body it requires 3-10 days incubation period before the disease appears. Infected people don’t pass the virus to others during the incubation period.Infected people don’t pass the virus to others during the incubation period. They become infectious only when the first symptoms appear; cough & sneezing which spread droplets containing the virus particles.They become infectious only when the first symptoms appear; cough & sneezing which spread droplets containing the virus particles. Incubation period

SARS Case definition SARS case is defined according to:- I. Clinical Criteria II. Epidemiological Criteria III. Laboratory Criteria

I. Clinical Criteria Asymptomatic, or mild respiratory illness. Asymptomatic, or mild respiratory illness. Moderate respiratory illness:Moderate respiratory illness: - High fever > 38°C, and - High fever > 38°C, and - one or more findings of respiratory illness; (cough, shortness of breath,breathing difficulty,or hypoxia). - one or more findings of respiratory illness; (cough, shortness of breath,breathing difficulty,or hypoxia). SARS Case “cont.”

Severe respiratory illness: - High fever > 38°C, and - High fever > 38°C, and - one or more findings of respiratory illness (cough, shortness of breath,breathing difficulty,or hypoxia), and - one or more findings of respiratory illness (cough, shortness of breath,breathing difficulty,or hypoxia), and - radiographic evidence of pneumonia, or - radiographic evidence of pneumonia, or respiratory distress syndrome, or respiratory distress syndrome, or - autopsy findings consistent with pneumonia or RDS without an identifiable cause. - autopsy findings consistent with pneumonia or RDS without an identifiable cause. SARS Case “cont.” SARS Case “cont.”

II. Epidemiological Criteria  Travel “ including transit in an airport within 10 days of onset of symptoms” to an area with current or recently documented or suspected community transmission of SARS, or  Close contact within 10 days of onset of symptoms with a person known or suspected to have SARS infection. SARS Case “cont.”

III. Laboratory Criteria  Confirmed - Detection of antibodies to SARS-CoV in specimens obtained during acute illness or > 21 days after illness onset,or - Detection of antibodies to SARS-CoV in specimens obtained during acute illness or > 21 days after illness onset,or - Detection of SARS CoV RNA RT-PCR confirmed by second PCR assay, by using a seconed aliquot of the specimen and a different set of PCR primers, or - Detection of SARS CoV RNA RT-PCR confirmed by second PCR assay, by using a seconed aliquot of the specimen and a different set of PCR primers, or - Isolation of SARS-CoV. SARS Case “cont.”

Negative: - Absence of antibodies to SARS-CoV in convalescent serum obtained >21 days after symptoms onset. - Absence of antibodies to SARS-CoV in convalescent serum obtained >21 days after symptoms onset.  Undetermined : - Laboratory testing either not performed or incomplete. - Laboratory testing either not performed or incomplete. SARS Case “cont.”

Probable Case meets the following : - clinical criteria for severe respiratory illness of unknown etiology with onset sience Feb. 1,2003, and - clinical criteria for severe respiratory illness of unknown etiology with onset sience Feb. 1,2003, and - epidemiological criteria, - epidemiological criteria, * laboratory criteria might be confirmed, negative, or undetermined. * laboratory criteria might be confirmed, negative, or undetermined. SARS Case “cont.”

Suspect Case meets the following : - clinical criteria for moderate respiratory illness of unknown etiology with onset since Feb. 1,2003, and - clinical criteria for moderate respiratory illness of unknown etiology with onset since Feb. 1,2003, and - epidemiological criteria, - epidemiological criteria, * laboratory criteria might be confirmed, negative, or undetermined. * laboratory criteria might be confirmed, negative, or undetermined. SARS Case “cont.”

I. Respiratory tract specimens A. Upper Respiratory Tract: nasopharyngeal wash/aspiratenasopharyngeal wash/aspirate Nasopharyngeal swabsNasopharyngeal swabs Oropharyngeal swabsOropharyngeal swabs B. Lower Respiratory Tract: broncheoalveolar lavage,broncheoalveolar lavage, tracheal aspirate,or pleural tap.tracheal aspirate,or pleural tap. II. Blood III. Stool IV. TISSUE SPECIMENS (for deceased patients) SARS Diagnosis ;Specimens

Antibody tests Antibody tests -ELISA : after day 21 of illness onset. - IFA :after about day 10 of illness onset. Molecular testsMolecular tests PCR: detect genetic material of the SARS virus in various specimens (blood, stool, respiratory secretions or body tissue). or body tissue). “available by WHO network laboratories on the WHO web site “ WHO web site WHO web site SARS Diagnosis ;laboratory tests

Early in the disease:Early in the disease: -lymphopenia. Early in the respiratory phase: - elevated CPK and -ALT & AST (2-6 times the upper limits of normal). At the peak of the respiratory illness,At the peak of the respiratory illness, 50% of patients have: 50% of patients have: - leukopenia and - thrombocytopenia. Renal function remains normal.Renal function remains normal. *** Lab. Investigations “cont.”

At present, the most effective treatment regimen, if any, is unknown. Symptomatic : there is no specific treatment. Symptomatic : there is no specific treatment. Antibiotics to treat known bacterial agents of atypical pneumonia.Antibiotics to treat known bacterial agents of atypical pneumonia. Antiviral agents such as ribavirin,(?Interferon)Antiviral agents such as ribavirin,(?Interferon) Steroids in combination with ribavirin and other antimicrobials.Steroids in combination with ribavirin and other antimicrobials. Post infection immunityPost infection immunity : not yet determined. SARS Treatment

Patient with symptoms of SARSPatient with symptoms of SARS 1. should be examined in - rooms, or - wards designated for that purpose. 2. Patients should wear surgical masks. Management of suspect cases

3. Obtain and record detailed: - clinical, - travel, and - contact history during last 10 days. 4. chest x-ray and 5. full blood count. 6. Hospitalize under isolation and treat as clinically indicated. Management of suspect cases”cont.”

For People Who Are Ill.For People Who Are Ill. Separates them from healthy people andSeparates them from healthy people and Restricts their movement to stop the spread of that illness.Restricts their movement to stop the spread of that illness. Protects healthy people from getting sick.Protects healthy people from getting sick. People in isolation may be cared for in their homes, in hospitals, or at designated health care facilities.People in isolation may be cared for in their homes, in hospitals, or at designated health care facilities. *Isolation :

Applies to people who have been exposed and may be infected butApplies to people who have been exposed and may be infected but are not yet ill. are not yet ill. Separating exposed people and restricting their movements to stop the spread of that illness.Separating exposed people and restricting their movements to stop the spread of that illness. Quarantine is medically very effective in protecting the public from disease. Quarantine is medically very effective in protecting the public from disease. * Quarantine :

Provide reassurance.Provide reassurance. Record name and contact details.Record name and contact details. Provide advice in the event of fever or respiratory symptoms to :Provide advice in the event of fever or respiratory symptoms to : 1- I mmediately report to doctor. 2- N ot report to work until advised by health authority. 3- A void puplic places until advised by health authority. 4- M inimize contact with family members and friends. Management of contacts of suspected and probable cases

1. Restriction of travel to affected areas -Persons traveling to affected areas, consider postponing all but essential travel. postponing all but essential travel. 2. Measures for point of departure -Screening of suspected cases of SARS on departure from affected areas, whether the departure from affected areas, whether the passenger: passenger: Has any symptoms of SARS within the past 48Has any symptoms of SARS within the past 48 hours. hours. *Any contact with SARS cases. *Has a fever. WHO recommendations for prevention of international spread of SARS

3.Measures on board In-flight care of suspected case of SARS: -The passenger should be, as far as possible, isolated from other passengers and crew. - The passenger should be asked to wear a protective mask. - persons caring for the ill passenger should follow the infection control measures recommended for cases of SARS.

- A toilet should be identified and made available for the exclusive use of the ill passenger. - The captain should radio ahead to airport of destination, so that health authorities are alerted to arrival of suspect case of SARS

4.Measures at destination * Management of the ill passenger: - The passenger should be placed in isolation and assessed by port health authorities. - If the immediate medical assessment in the airport concludes that the passenger is a suspect or probable case of SARS, the patient should be isolated.

- If the immediate medical assessment excludes SARS as a possible cause of illness,the passengers should be referred to local health care facilities for any necessary follow up.

* Management of other passengers: - Passengers and crew should be screened at destination, using the same methods on departure. - according to the result of their screening the passengers are to be dealt with: I. Passengers identified as suspect case should be isolated.

II. Passengers who were in contact with suspect or probable case : -Should provide identification and details of address/contact details valid for 14 days. -Should be given information about SARS and advise to seek immediate medical attention if advise to seek immediate medical attention if they develop any symptoms of SARS within 10 they develop any symptoms of SARS within 10 days of the flight. days of the flight. - Should be allowed to continue travel so long as they don’t have symptoms compatible with they don’t have symptoms compatible with SARS. SARS.

*** In order to respond as recommended by WHO, airlines will have to ensure that flights serving SARS affected areas are provided with sufficient : - gloves, - face masks, - disinfectant, and * a seat in an isolated area can be made available when needed.

Hospital Infection Control Guidance I.Suspect or probable case. II.Health Care Workers. III.Respirators. IV.Waste Disposal. V.Hand washing.

I. Suspect or probable Case If a suspect SARS patient is admitted to the hospital, infection control personnel should be notified immediately. Infection control measures for inpatients should include:Infection control measures for inpatients should include: 1. Standard precautions (e.g., hand hygiene) 2. Contact precautions (e.g., gown & gloves) 3. Airborne precautions(e.g., N95 respirator) Hospital Infection Control Guidance”cont.”

Suspect cases should wear surgical masks until SARS is excluded.Suspect cases should wear surgical masks until SARS is excluded. Patients with probable SARS should be isolated as follows in descending order of preference :Patients with probable SARS should be isolated as follows in descending order of preference : 1- negative pressure rooms. 2- single room with their own bathroom. 3- cohort placement in an independent air supply and exhaust system. Hospital Infection Control Guidance”cont.”

Turning off air conditioning and open windows for good ventilation if independent air supply is not available.Turning off air conditioning and open windows for good ventilation if independent air supply is not available. Patients under investigation for SARS should be separated from those diagnosed with the syndrome.Patients under investigation for SARS should be separated from those diagnosed with the syndrome. Patient movement should be avoided as much as possible.Patient movement should be avoided as much as possible. Hospital Infection Control Guidance”cont.”

II. Health care workers : Strict adherence with the barrier nursing of patients with SARS using precautions for airborn, droplet and contact transmission.Strict adherence with the barrier nursing of patients with SARS using precautions for airborn, droplet and contact transmission. Triage nurses should rapidly divert persons presenting to their health care facilities with flu-like symptoms to a separate assessment area to minimize transmission to others in the waiting room.Triage nurses should rapidly divert persons presenting to their health care facilities with flu-like symptoms to a separate assessment area to minimize transmission to others in the waiting room. Hospital Infection Control Guidance

- health care workers are advised to wear gloves for all patient handling. - gloves should be changed between patients and after any contact with items likely to be contaminated with respiratory secretions. - gloves should be changed between patients and after any contact with items likely to be contaminated with respiratory secretions. - gowns ( waterproof) and head covers should be worn during procedures and patient activities. - gowns ( waterproof) and head covers should be worn during procedures and patient activities. Hospital Infection Control Guidance”cont.”

- health care workers must wear protective eyewear, face-shields and masks (N95) during procedures where there is potential for splashing, splattering or spraying of blood or other body substances. - health care workers must wear protective eyewear, face-shields and masks (N95) during procedures where there is potential for splashing, splattering or spraying of blood or other body substances. - standard precautions should be applied when handling any clinical wastes. - standard precautions should be applied when handling any clinical wastes. Hospital Infection Control Guidance”cont.”

Disposable equipment should be used in the treatment and care of patients.Disposable equipment should be used in the treatment and care of patients. Gloves should be changed between patients and after any contact with contaminated items.Gloves should be changed between patients and after any contact with contaminated items. Reused devises, should be sterilized, and the surface should be cleaned with broad spectrum disinfectant.Reused devises, should be sterilized, and the surface should be cleaned with broad spectrum disinfectant. Hospital Infection Control Guidance”cont.”

III. Respirators Patients being moved should wear a surgical mask to minimize dispersal of droplets.Patients being moved should wear a surgical mask to minimize dispersal of droplets. All visitors,staff,students andAll visitors,staff,students and volunteers should wear a N95 mask ”capable of filtering 0.3um particles” on entering the room of patient with confirmed or suspected SARS. Surgical masks are a lessSurgical masks are a less effective alternative to N95 masks. Hospital Infection Control Guidance”cont.”

IV. Waste Disposal : Dry soiled waste; used gloves, dressings,etc.:Dry soiled waste; used gloves, dressings,etc.: collected in biohazards bags. Waste that saturated with blood, body fluids or excreta :Waste that saturated with blood, body fluids or excreta : collected in leak-proof biohazards bags. Sharp items; used needles, scalpel blades,etc.:Sharp items; used needles, scalpel blades,etc.: collected in puncture resistant sharps containers. Suction fluids & secretions:stored in sealed containers.Suction fluids & secretions:stored in sealed containers. Hospital Infection Control Guidance”cont.”

V.Hand-washing - The most important measure in preventing the spread of infection. the spread of infection. - Gloves are not a substitute for hand- - Gloves are not a substitute for hand- washing. washing. - Hands should be washed before and after - Hands should be washed before and after removing gloves. removing gloves. - Alcohol-based skin disinfectants may be - Alcohol-based skin disinfectants may be used in certain limited circumstances. used in certain limited circumstances. Hospital Infection Control Guidance”cont.”