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 !