sars situation in guangdong and hospital infection control xiaoping tang, m.d, ph.d guangzhou no. 8...

SARS Situation in GuangdongSARS Situation in Guangdong and Hospital Infection Control and Hospital Infection Control

Xiaoping Tang, M.D, Ph.D

Guangzhou No. 8 People’s Hospital

Number Of SARS Patients and HCW Infection (AS of 8/7/2003) Cases Death (%) HCW(%) Last Report

Global 8422 916 11 1725(20) 7.13

China(Main) 5327 349 7 1002(19) 6.25

Guangdong 1512 58 4 346(23) 6.25

Hongkong 1755 300 17 386(22) 5.31

Taiwan 665 180 27 86(13) 6.15Canada 251 41 17 108(43) 6.12Singapore 283 33 14 97(41) 5.05

Foshan Cases

In November, 2002 A cluster of 5 cases of

Pneumonia from one family were hospitalized, 2 developed to RF

（ First case : onset time Nov 16 ）

Large shadows in Lungs No Response to

Antibiotics X-Ray

Heyuan Cases

• Mr. Huang, a restaurant cook, got sick on Dec.10 in Shenzhen

• admitted to Heyuan 1st Hospital on Dec.15， 2002

• A cluster of cases including 8 HCW happened

First case in Heyuan

Zhongshan Cases

• January 20, 20 cases were reported to Guangdong Health Bureau.

• Jan. 21, experts from Guangzhou, Foshan, Heyuan and China CDC had consultation together.

Guangzhou Super-spreader

90

Total Patients Received

• 1st patients: Feb 2, 2003

• Total : 413 probable & suspect cases

(262 confirmed )

5

118142

109

2743 52 47

30 33 3313

2 10

50

100

150

Number of Pati ents i n Hospi tal

Male 124

Female 138

Age 2-89 years old

average 41±18

SARS contacting history 175 (67.3%)

Incubation period 1-14 d

average 4.5 d

General Information

Clinical features (%) Hong KongLee et al(n=138)

TorontoBooth et al (n=144)

Hong KongPeiris et al

(n=50)

GuangzhouZhang et al

(n=260)

SingaporeHsu et al

(n=20)

Fever 100 99.3 100 100 100

Chills/rigor 73.2 27.8 74 51.2 15

Myalgia 60.9 49.3 54 26.5 45

Cough 57.3 69.4 62 72.7 75

Dyspnoea -- 41.7 20 75.4 40

Headache 55.8 35.4 20 26.5 20

Dizziness 42.8 4.2 12 46.5 --

Sputum 29.0 4.9 -- 11.5 --

Diarrhoea 19.6 23.6 10 24.2 25

Nausea & vomiting 19.6 19.4 20 -- 35

Sore throat 23.2 12.5 20 -- 25

Malaise -- 31.2 50 24.6 45

Presenting Symptoms

Laboratory Findings (1)

Leucocyte >10 ×109/L 38 (14.6%)

4.0~10 ×109/L 146 (56.2%)

< 4.0 ×109/L 76 (29.2%)

< 2.0 ×109/L 35 (13.5%)

Lymphocyte < 1.5 ×109/L 226 (86.9%)

Platelet < 10 ×109/L 25 (9%)

the lowest 2.5 ×109/L

Laboratory Findings (2)

LDH increase 121 (46.5%)

CK increase 106 (40.8%)

ALT increase 174 (66.9%)

AST increase 136 (52.3%)

BUN 28 (10.8%)

CD4 + lymphocyte 475.6 ± 405.2/ul

< 400/ul 56/93 (60.2%)

< 200/ul 30/93 (32.3%)

the lowest 23/ul

SO2 < 95% 101 (38.8%)

Laboratory Findings (3)Laboratory Findings (3)

1527

787633

954

551

371472

244 202

0

200

400

600

800

1000

1200

1400

1600

1800

2000

2200

CD3+ CD4+ CD8+

Normal

Mild

Severe

T Lymphocyte Subtypes (1)

257147 101

935

507397

0

200

400

600

800

1000

1200

1400

1600

CD3+ CD4+ CD8+

Dead

Alive

T Lymphocyte Subtypes (2)

Chest X-ray

Interstitial damage 184 (70.7%)

Small patch-like or spotty shadow 195 (75%)

Large patch-like shadow 161 (61.9%)

Reticular opacities 93 (35.8%)

Both lung involvement 192 (73.8%)

Management

• Oxygen taking

• Antibiotics: empirically

• Anti-viral reagents : Ribavirin

• Glucocorticoid (Methyprednisolone)

• Artificial Ventilator support

Corticosteroid Management

Early systemic corticosteroid administrationAutopsy showed: hyalinization of airway basal membrane, alveolar fibrosis (similar to ARDS)

Indication:

High fever>3 days

Chest X ray deteriorates progressively

Dose of methylprednisolone in Guangzhou No.8 Hosp

• Dose of MP 140±123mg/d (40~500mg/d)

• Duration 14±12 days

• N=54

No-invasive Positive Pressure Ventilation (CPAP/BiPAP)

Indications:

1. RR>30times/min ；

2.SaO2< 93% when taking

oxygen 3-5L/min

3 、 Difficulty in breathing

No.8 Hosp. N=54/262

Average time of hospitalization

Common type 13.8 ± 3.5 d

Severe type 28.4 ± 10.3 d

Fatality rate 4.2% (12/260)

Prognosis

Mortality in Guangzhou

Total cases 1274

Dead 46 3.61%

70% (892 cases) with IgG titer 4 times higher than normal

Mortality 46/892 = 5.16%5.16%

Low mortality in Guangdong (why?) (1)

• Misdiagnosis

• Less worse epidemics

– Peak < 60 newly diagnosed pts/day

• Age distribution ?

• Fewer patients with underlying diseases?

Low mortality in Guangdong (why?) (2)

• Critical Cases

• Medical staff

• Guideline - better efficacy with combined man

agement (lower dose corticosteroid +CPAP/Bi

PAP)

referred to well-equipped referred to well-equipped

and well-trained hospitalsand well-trained hospitals

Distribution of death relating to age (n=931)

Age

(yrs)<15 15-20 20-30 30-40 40-50 50-60 60-70 >70 Total

Case 12 47 287 255 161 82 50 37 931

Death 0 0 1 5 13 5 7 4 35

% 0 0 0.4 2.0 8.1 6.1 14 11 3.7

Underlying Disease relating to death (n=931)

Total With underlying disease

No underlying disease

Case 931 190 (20.4%) 741 (79.6%)

Death 35 15 20

% 3.7 7.9 2.7

Underlying diseases—Diabetes, COPD, chronic asthma, cancer, chronic renal disease, hypertension, pulmonary TB, chronic hepatitis, chronic heart failure, etc

A comparison of Intubation Rate and Crude Fatality Rate in SARS patients

NNCPAPCPAP

(BiPAP)(BiPAP)IntubationIntubation FatalityFatality

Hong Kong 175535

(2.0%)

246

(14.0%)

300

(17.1%)

Guangzhou 528122

(23.1%)

39

(7.4%)

29

(5.5%)

P

(X2 test)

<0.001

(228.3)

<0.001

(16.3)

<0.001

(43.6)

Hospital Infection Control

Number Of SARS Patients and HCW Infection (AS of 8/7/2003) Cases Death (%) HCW(%) Last Report

Global 8422 916 11 1725(20) 7.13

China(Main） 5327 349 7 1002(19) 6.25

Guangdong 1512 58 4 346(23) 6.25

Hongkong 1755 300 17 386(22) 5.31

Taiwan 665 180 27 86(13) 6.15Canada 251 41 17 108(43) 6.12Singapore 283 33 14 97(41) 5.05

Medical Staff Infection in Our Hospital

• Total 20 (8 doctors, 12 nurses)

• Happened during the time when there

were most patients ( from Feb. 12 to

Feb.19 )

• All recovered

After Bitter Experiences

More Strict Hospital Preventive

Measures were Taken by Medical Staff

Separated Fever Clinic

Thank You !