PPHSN Guidelines SARS 9Th April 03-Figure1:Clinical Picture in SARS Patients

PPHSN Guidelines

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

April 9th 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. These guidelines have also been ‘harmonised’ with the WHO WPRO guidelines published on 4th April.

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Table of Contents

BASIC DISEASE FACTS (updated 09.04.2003)

Background

Description of disease

Epidemiology

Agent and infectious dose

Source

Occurrence

Mode of transmission

Period of communicability

Incubation period

Vulnerable population sub-groups

Risk in the Pacific

SURVEILLANCE (updated 09.04.2003)

PPHSN Case Definitions for hospital based surveillance

Suspected case

Probable case

Surveillance and reporting

Minimum dataset

PREPAREDNESS – INITIAL ACTION AND RESPONSIBILITIES (updated 09.04.2003)

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, & coordination among agencies

CASE MANAGEMENT – the clinical response (updated 09.04.2003)

Investigations

CXR

FBC

Other

Management of suspect cases

In-flight care of suspected case of SARS

General care of suspected case of SARS

Management of probable cases

Specific Treatment

Hospital discharge and follow-up

HOSPITAL INFECTION CONTROL (updated 09.04.2003)

Care for patients with probable SARS

General Principles

Principles of isolation

Principles of Personal Protective Equipment (PPE)

Who should use PPE?

Minimum PPE to be worn

How should PPE be used?

Masks

Goggles/Eye wear

Putting on PPE before entering isolation area (In order of dressing)

Taking off PPE when leaving isolation area

Linen, cleaning and clinical waste

MANAGEMENT OF CONTACTS OF SUSPECTED & PROBABLE CASES (updated 09.04.2003)

General

Contact tracing

Contacts of probable cases

Contacts of suspected cases

Contacts of suspected cases on aircraft

Reducing the risk of importing SARS through international travel (updated 09.04.2003)

WHO recommendations to limit the spread of SARS by international travel

Travellers' Alert

Advice to airline staff and national airport health authorities

Disinfection of aircraft

REFERENCES AND FURTHER SOURCES OF INFORMATION (updated 09.04.2003)

ANNEXES (updated 09.04.2003)

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Severe Acute respiratory Syndrome (SARS)

BASIC DISEASE FACTS (updated 09.04.2003)

Background

As of 08 April 2003, reports of over 2671 cases, including 103 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 the epidemic started in Guangdong in November 2002. Local transmission occurred in the following areas: Guangdong and Shanxi provinces and the Special Administrative Region of Hong Kong in China, Taiwan in China, Hanoi in Vietnam, Singapore and Toronto in Canada. Only imported cases were reported in 13 other countries.

It is currently agreed that a new coronavirus (“SARS virus”) is the major

causative agent of SARS. 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; about half of these have needed ventilator support.

As of 09 April 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.

All modes of transmission 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

The search has been progressively narrowed to members of the paramyxovirus and coronavirus families, and it is currently agreed that a new coronavirus, “SARS virus”, is the major

causative agent of SARS. 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

The agent is spread from person to person through respiratory droplets and contact (including fomites). Airborne transmission appears uncommon if it occurs at all and transmission through environmental factors is being investigated.

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 (see figure 1).

Incubation period

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

Vulnerable population sub-groups

Health care workers and immediate family members and friends of SARS cases are at extreme risk of becoming a case.

Secondary cases from air travel are reported.

Insufficient information available at this stage about who is at risk to become severe ill and die. 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.

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SURVEILLANCE (updated 09.04.2003)

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

PPHSN Case Definitions for hospital based surveillance

Suspected case

Clinicians should be alert for persons with onset of illness after November 1, 2002 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 14 days of onset of symptoms, with a person who has been diagnosed with SARS.
• history of travel, within 14 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.

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 14 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 (through local WHO Office if present) 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

• Upon arrival:

• affected area visited in the last 10 days and presence of symptoms.
• identity of individuals and residence/contact in the next 14 days (purpose: active surveillance/retrieving contacts of suspected or probable case on board a plane or boat).
• national health or port authorities may consider routinely collecting a copy of the passenger seating list of every flight arriving from SARS affected areas.

• 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).

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PREPAREDNESS – INITIAL ACTION AND RESPONSIBILITIES (updated 09.04.2003)

• Countries should set up a response structure at the national level as a matter of urgency and develop a contingency plan for SARS.

• A cornerstone of this plan is close collaboration between public health departments (disease control unit), clinical departments treating patients and laboratories.

Staff responsibilities for the various actions

• At the ministry of health level, a task force including the EpiNet team and with one national focal point, an expert committee and a surveillance unit with a hotline must be set up.

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

Priority functions of the task force are to:

• identify the facility(ies) 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 individual arrives ill on a plane with suspected SARS.

• The task force should be responsible for all the issues concerning SARS including establishing good communications. The expert committee should be responsible for making a decision on the public health response to reported cases.

• An urgent task of this task force will be establishing a national surveillance system. The surveillance system should also include private hospital and clinics. Information should be provided for the media and general public.
• Designate at least one hospital to isolate cases and one laboratory responsible for managing clinical samples. Good communications should be established between the national focal point and the designated hospital and the designated laboratory. (see Figure 2)
• The tasks at national level includes development of inventory of barrier nursing supplies, community infection control, quarantine at port of entry, and public awareness (avoiding panic).

Figure 2: Information Flows

1 & 2 Information collected from government and private hospitals, the media and the general public

3 Reports should be verified by surveillance unit

4 The information should be shared with the designated hospital and laboratory focal point as well as the WHO focal point if available, or PPHSN Coordinating Body focal point (SPC).

5 In principle, probable cases should be transferred to the designated isolation facility for further assessment, treatment and infection control. This should be decided by the task force or expert committee on a case-by-case basis

6 Specimens should be collected under the supervision of the laboratory focal point following the guidelines and transferred to an international laboratory if necessary

Clinical assessment of suspected patients

• Clinicians must be aware of the symptoms and signs of SARS.

• Patients with symptoms of SARS and a history of travel from an affected area or contact with a case of SARS should be triaged immediately to designated examination rooms or wards to minimize exposure to other patients and staff.
• Where feasible, separate specific reception areas for triaging patients who may have SARS should be established
• Patients with suspected SARS should be issued with surgical masks.
• Medical and nursing staff must take precautions when examining the patient ie barrier nursing.
• Where material resources for barrier nursing are scarce, available supplies should be used sparingly in triage settings (such as by limiting the number of staff working in this area), so in the event of a SARS admission supplies will not have been exhausted.
• 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 or WHO Suva (through local WHO Office if present). 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 at this stage.
• 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 three laboratories in our region that have agreed to receive specimens are:
• Institute Pasteur, New Caledonia
• WHO Collaborating Centre for Reference and Research on Influenza, Australia
• Clinical Virology, Communicable Disease Programme, Institute of Environmental Science and Research (ESR), New Zealand

(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 introduced new travel advice on 4th April advising against travel to the worst affected areas (Hong Kong and Guandong Province in China), unless essential. The PPHSN SARS Task force has also produced a travel advisory that goes further than WHO (see ANNEX 3). 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, & 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).

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CASE MANAGEMENT – the clinical response (updated 09.04.2003)

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, neutrophilia may occur.

Other

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

Management of suspect cases