PPHSN Guidelines

For The Preparedness, Surveillance And Response To Severe Acute Respiratory Syndrome (SARS) in Pacific Island Countries And Territories

March 28th 2003

SARS is a new disease syndrome. Our knowledge about the best way to prevent and treat it is constantly evolving. These guidelines will be continuously updated. Please regularly check PPHSN website for the most up to date guidance

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PPHSN. SARS Guidelines

28/03/2003

Table of Contents

BASIC DISEASE FACTS

Background

Description of disease

Epidemiology

Agent and infectious dose

SURVEILLANCE

WHO Case Definitions for hospital based surveillance

Surveillance and reporting

Minimum dataset

PREPAREDNESS – INITIAL ACTION AND RESPONSIBILITIES

Outbreak response team (EpiNet or CDC other committee)

Staff responsibilities for the various actions

Clinical assessment of suspected patients

Enhanced surveillance

Communications (between members of team and with outside bodies, media etc.)

Laboratory diagnosis

Initial community interventions

External (international) reporting, requests for support, and coordination among agencies

CASE MANAGEMENT – the clinical response

Investigations

Management of suspect cases

Management of probable cases

Specific Treatment

Hospital discharge and follow-up

HOSPITAL INFECTION CONTROL

Care for patients with probable SARS

MANAGEMENT OF CONTACTS OF SUSPECTED AND PROBABLE CASES

General

Contacts of suspected cases on aircraft

REFERENCES AND FURTHER SOURCES OF INFORMATION

ANNEXES

HISTORY OF GUIDELINE

ANNEX 1

ANNEX 2

ANNEX 3

ANNEX 4

ANNEX 5

ANNEX 6

ANNEX 7

ANNEX 8......

ANNEX 9

ANNEX 10

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PPHSN. SARS Guidelines

28/03/2003

Severe Acute respiratory Syndrome (SARS)

BASIC DISEASE FACTS

Background

As of 27 March 2003, reports of over 1408 cases, including 53 deaths, of Severe Acute Respiratory Syndrome (SARS), an atypical pneumonia of unknown aetiology, have been received by the World Health Organization (WHO) since 16 November 2002. WHO is coordinating the international investigation of this outbreak and is working closely with health authorities in the affected countries to provide epidemiological, clinical and logistical support as required.

SARS was first recognised on the 26 February 2003 in Hanoi, Viet Nam, but it the epidemic started in Guangdong in November 2002. Local transmission occurred in China, Vietnam, Singapore and Canada. The worst-affected areas are Guangdong province and the Special Administrative Region of Hong Kong in China, Hanoi in Vietnam, and Singapore.

The causative agent has yet to be identified, although the search has been currently narrowed to members of the paramyxovirus and coronavirus families. The main symptoms and signs include high fever (>38 degrees Celsius), cough, shortness of breath or breathing difficulties. Approximately 10 percent of patients with SARS develop severe pneumonia; some of whom have needed ventilator support.

As of 27 March the majority of cases have occurred in people who have had very close contact with other cases; for this reason, health care workers are at particular risk.

Description of disease

The syndrome begins with fever for 1-2 days, then a dry cough or dyspnea for 2-3 days. Atypical pneumonia develops on day 4-5 in the majority of cases. It is initially unilateral but after a further 1-3 days it often becomes bilateral, progressing to extensive "white-out" on chest XRay.

The disease then takes 1 of 2 courses:

A) the patient improves (80-90% of cases) and recovers over the next 4-7 days; or
B) the patient deteriorates severely on day 6-7 with respiratory distress (10-20% of cases).

50% of patients in category B require mechanical ventilation. The mortality rate in this sub-group is high. During the early phase of the outbreak, around 50% of type B cases have died, giving an overall CFR of 5-10%. Risk factors for poor outcome are not clear, apart from the severity of illness and the need for mechanical ventilation. So far SARS has affected predominantly adults aged 20-70 yrs. Very few cases have occurred in children.

The modes of transmission and the causative agent have yet to be determined. Aerosol and/or droplet spread is likely as is transmission from body fluids. Respiratory isolation, strict respiratory and mucosal barrier nursing are recommended for cases. Cases should be treated as clinically indicated. (see below for further details).

Epidemiology

Agent and infectious dose

Some laboratories have reported finding paramyxovirus or coronavirus particles on electron microscopy of specimens taken from cases. However these findings await confirmation. The infectious dose is unknown.

Source

From the knowledge available to date the source of an infection is another person who is ill with SARS.

Occurrence

So far all cases reported from outside the affected areas have a history of travel in the previous 10 days through an affected area OR close contact with a case of SARS.

Mode of transmission

It is likely that the agent is spread from person to person by droplet/aerosol spread. However it may also be air-borne and transmission from contact with body fluids has not been excluded.

Period of communicability

Not known but particularly infectious once respiratory symptoms appear. A lower risk of transmission is likely to be present during the prodromal phase.

Incubation period

The incubation period is thought to be 2-7 days exceptionally 10 days, most commonly 3-5 days

Vulnerable population sub-groups

Insufficient information available at this stage. But probably worse outcomes can be expected in individuals with underlying respiratory and cardiac illnesses such as asthma, COPD and heart disease.

Risk in the Pacific

The main risk in the Pacific is the importation of cases from affected areas with subsequent local transmission to close contacts including health workers.

SURVEILLANCE

Please note that a SINGLE case of suspected/probable SARS is an outbreak.

WHO Case Definitions for hospital based surveillance

Suspected case

Clinicians should be alert for persons with onset of illness after February 1, 2003 with:

Fever (>38° C)

AND

One or more signs or symptoms of respiratory illness, including:

  • cough,
  • shortness of breath,
  • difficulty breathing,

AND

A history of either of the following:

  • close contact*, within 10 days of onset of symptoms, with a person who has been diagnosed with SARS.
  • history of travel, within 10 days of onset of symptoms, to an area** (see table below) in which there are reported foci of transmission of SARS.

* close contact means having cared for, having lived with, or having had direct contact

with respiratory secretions and body fluids of a person with SARS.

Affected Areas** - Severe Acute Respiratory Syndrome (SARS)
Country / Area
Canada / Toronto
Singapore / Singapore
China / Beijing, Guangdong Province, Hong Kong Special Administrative Region of China, Shanxi, Taiwan
Viet Nam / Hanoi
Last revised 27 March 2003
**An "Affected Area" is defined as a region at the first administrative level where the country is reporting local transmission of SARS.

Note

In addition to fever and respiratory symptoms, SARS may be associated with other symptoms including: headache, muscular stiffness, loss of appetite, malaise, confusion, rash, and diarrhea.

Probable case

  • A suspected case with chest X-ray findings of pneumonia or adult respiratory distress syndrome.

OR

  • A person with an unexplained respiratory illness resulting in death, with an autopsy examination demonstrating the pathology of Respiratory Distress Syndrome without an identifiable cause.

Surveillance and reporting

  • If travel questionnaires are issued to arriving passengers or passengers from affected areas are requested to identify themselves, record number of arrivals with a travel history that puts them in the at risk group (travel to an affected area within the previous 10 days).
  • Report all suspected/probable cases immediately to National Public Health Authorities, using the PPHSN reporting form (see ANNEX 2).
  • Report all suspected/probable cases immediately to PPHSN Coordinating Body (CB) Focal point or WHO Suva using the PPHSN reporting form (a copy of the completed form used to report to the National Public Health Authorities) (see contacts list in ANNEX 1)
  • Report to PacNet or PacNet-restricted.

Minimum dataset

  • [Optional: upon arrival, affected area visited in the last 10 days and presence of symptoms]
  • Please see PPHSN reporting form for data items.
  • For PacNet or PacNet-restricted, same as on reporting form, EXCEPT reporter and patient details (you can send the form on PacNet or PacNet-restricted, but delete the 2nd page).

PREPAREDNESS – INITIAL ACTION AND RESPONSIBILITIES

This will depend on local arrangements within each country.

Outbreak response team (EpiNet or CDC other committee)

For the purpose of proper SARS control in hospital environment, this team should include a member experienced in hospital infection control, and who can advise on isolation and barrier nursing issues.

Priority functions of the team are to:

  • identify facilities where suspected and probable cases of SARS can be nursed.
  • perform an inventory of supplies required for nursing such patients (using WPRO SARS Preparedness Kit contents list).
  • plan how contacts of suspect/probable cases will be managed
  • liaise with customs/immigration authorities on the best way to provide information to arriving passengers, record travel details for surveillance and plan of action if an ill individual arrives ill on a plane with suspected SARS.

Staff responsibilities for the various actions

  • Individual countries to decide

Clinical assessment of suspected patients

  • Clinicians must be aware of the symptoms and signs of SARS.
  • Patients with symptoms of SARS should be triaged immediately to designated examination rooms or wards to minimize exposure to other patients and staff.
  • Patients with suspected SARS should be issued with surgical masks.
  • Medical and nursing staff must take precautions when examining the patient ie barrier nursing.
  • Obtain and record detailed clinical, travel and contact history including occurrence of acute respiratory diseases in contact persons during the last 10 days.
  • Obtain chest X-ray (CXR) and full blood count (FBC).

(See example patient management flow chart in ANNEX 4)

Enhanced surveillance

  • Complete PPHSN reporting form and send immediately to National Health Authorities, with a cc to PPHSN-CB Focal Point. Also send immediately the form WITHOUT reporter and patient details (i.e. page 2) to PacNet or PacNet-restricted
  • Identify close contacts and give information to contacts. Screen any contacts with compatible symptoms as for suspected cases.

Communications (between members of team and with outside bodies, media etc.)

  • Ensure that lines of communication are clear.
  • Identify spokesperson for the team who will be the focal point for media briefings and will liaise with international agencies eg WHO/SPC (this could be the EpiNet team Focal Point or another person).

Laboratory diagnosis

  • The agent causing SARS remains to be established. There are no specific diagnostic tests.
  • For suspected cases where the diagnosis of SARS is by exclusion and the patient is not very ill (ie no chest X-ray changes compatible with SARS). It is reasonable to take specimens for diagnostic purposes. However health care workers must take full barrier nursing precautions to protect themselves from aerosols or splashing/splattering of blood or other body fluids.
  • For probable cases where the diagnosis of SARS is very likely and particularly if the patient has significant respiratory symptoms. The clinicians must perform a risk/ benefit analysis. There have been documented cases of transmission to HCWs during diagnostic/therapeutic procedures, particularly those prone to the generation of aerosols. Therefore the priority should be for tests likely to influence the clinical management of the patient.
  • If specimens are collected for diagnostic testing (rather than clinical management), they should be stored under appropriate conditions. At this stage, the two laboratories in our region that have agreed to receive specimens are:
  • Institute Pasteur, Noumea
  • WHO Collaborating Centre for Reference and Research on Influenza, Australia

(See Contact List in ANNEX 1 for addresses)

Initial community interventions

  • Provide suitable information to arriving passengers (particularly those who have traveled through affected countries) about the risks of SARS and where they can go to for advice and assistance (as example, see Advice to Arriving Travelers in ANNEX 5).
  • Simple health education messages should be communicated to the public via appropriate media (see Health Advices from Hong Kong in ANNEXES 6 and 7 for examples).
  • WHO has not recommended restricting travel to any destination in the world. However, all travellers should be aware of the main symptoms and signs of SARS, as given above. On the other hand, the CDC, the French Department of Health, Health Canada, New Zealand Ministry of Health and Singapore advise persons planning elective or nonessential travel to the worst-affected areas to postpone their trips until further notice. This careful attitude helps to avoid SARS long-distance spread through travel to and from infected zones and prevents the importation of SARS "home" (lots of close contacts...). This is particularly important in places where control measures may not be easy to implement (and SARS importation may have serious public health consequences).

External (international) reporting, requests for support, and coordination among agencies

  • Report all suspect and probable cases to PPHSN/WHO using the PPHSN reporting form
  • Contact PPHSN-CB Focal Point or WHO South Pacific if additional information or assistance is required (see contact list in ANNEX 1).

CASE MANAGEMENT – the clinical response

Investigations

CXR

  • Chest radiographs might be normal during the febrile prodrome and throughout the course of illness. However, in a substantial proportion of patients, the respiratory phase is characterized by early focal infiltrates progressing to more generalized, patchy, interstitial infiltrates. Some chest radiographs from patients in the late stages of SARS have also shown areas of consolidation.
  • In typical severe cases, chest x-ray findings begin with a small unilateral patchy shadow, and progress over 24 - 48 hours to become bilateral, generalized, interstitial/confluent infiltrates. Patchy chest x-ray changes are sometimes noted in the absence of chest symptoms. Acute respiratory distress syndrome might be observed in the end stage. Post-mortem lung tissue shows generalized alveolar damage and lymphocytosis without obvious viral inclusion bodies.

FBC

  • Initially the blood picture is often normal. However, by day 3 - 4 of the illness, lymphopenia is commonly observed (>50%), and less commonly, there might be thrombocytopenia. If SARS is complicated by secondary bacterial infection, neutrophilai may occur.

Other

  • Elevated hepatic transaminases and creatine phosphokinase levels are seen early in the respiratory phase of the disease.

Management of suspect cases

In-flight care of suspected case of SARS

  • If a passenger on a flight from an affected area becomes noticeably ill with a fever and respiratory symptoms, the following action is recommended for cabin crew:
  • The passenger should be, as far as possible, isolated from other passengers and crew
  • The passenger should be asked to wear a protective mask and those 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 alert the airport of destination so that quarantine or health authorities are altered to the arrival of a suspect case of SARS
  • On arrival, the ill passenger should be placed in isolation and assessed by port health authorities

General care of suspected case of SARS

  • Patients with symptoms of SARS should be triaged immediately to designated examination rooms or wards to minimize exposure to other patients and staff.
  • Patients with suspected SARS should be issued with surgical masks
  • obtain and record detailed clinical, travel and contact history including occurrence of acute respiratory diseases in contact persons during the last 10 days
  • obtain chest X-ray (CXR) and full blood count (FBC)

if CXR is normal:

  • provide advice on personal hygiene, avoidance of crowded areas and public transportation, remain at home until well with daily clinical follow-up [Singapore teaches patients under "domestic quarantine" to take and record their own temperatures 4-hourly, which the health worker reviews daily].
  • discharge with advice to seek medical care if respiratory symptoms worsen

if CXR demonstrates uni- or bi-lateral infiltrates with or without interstitial infiltration

  • SEE MANAGEMENT OF PROBABLE CASES

Management of probable cases

  • hospitalize under isolation or cohorted with other SARS cases (see section on Hospital infection control)
  • Cases need to be in the best isolation facility that can be arranged (this will vary for PICs) and must be nursed using strict barrier techniques including gown or preferably overalls, gloves, boots or over-shoes, HEPA or N95-100 mask (or at least a surgical mask if nothing else available) and goggles - not pleasant to use in PIC climate!
  • samples for laboratory investigation (if possible) and exclusion of known causes of atypical pneumonia:
  • throat and/or nasopharyngeal swabs[1]
  • blood for culture and serology (acute specimen and convalescent specimen taken after 3 weeks)
  • urine
  • bronchoalveolar lavage
  • post mortem examination as appropriate

Samples should be investigated in laboratories with proper containment facilities (BL3).

  • CXR as clinically indicated
  • treat as clinically indicated

Specific Treatment

  • Treatment regimens have included several antibiotics to presumptively treat known bacterial agents of atypical pneumonia.
  • In several locations, therapy has included antiviral agents such as oseltamivir or ribavirin; the effectiveness of these treatments is uncertain..
  • Steroids have also been administered orally or intravenously to patients in combination with ribavirin and other antimicrobials. Intravenous steroids may be associated with improved outcomes in severe cases.
  • At present, the most efficacious treatment regime, if any, is unknown.
  • Empirical antibiotic therapy should cover causes of community acquired pneumonia including both typical and atypical respiratory pathogens.

Hospital discharge and follow-up