the war on sars

8/10/2019 The War on SARS

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The War on SARS

National Epidemiology

Center Department ofHealth



Background•Suspected to haveoriginated in Guandong,China

•November 2002 – outbreakof SARS in China

•February 2003 – reported outside China

•March 12, 2003 – WHO issued globalalert

•March 17 – Philippine DOH started response

•April 11 – first Philippine probable casereported



http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5212a1.htm

International spread from hotel in Hong Kongto Viet Nam, United States, Singapore, Canada, Ireland



Epidemiological features

- health care workers and closecontacts at highest risk

- strict isolation and infectioncontrol can halt spread

- ? super-infectors (“super-spreaders”) vs. high socialmobility with many contacts



Clinical features

incubation period

exposure to SARS case

prodrome lower respiratory phase

1 to 13 days(~2 to 5 days)

~2 daysfever (>38ºC)

begins ~ day 3fever, dry cough,short of breathCXR changes

? very low / low low high / super-infectors

infectivity



Clinical features

continued illness

then

severe respiratory phase~10%

~90%

intubationmechanical ventilation

death <4%

O2 supportslow recovery

In the first 10 patients in HK,only one patient discharged:off supplemental O2 day 12;CXR resolution day 18;

discharge day 20;still with malaise day 26.

infectivity: unclear, possibly high to very high

patients still isolated on discharge



Infectious Agent• Cause mild to moderate respiratory illnesses such as

common cold.

• Able to survive in inanimate objects for up to 4 hours; atpresent, evidence points to survival of 2-4 days

• Can be killed by exposure to ultra-violet light, so theywill not survive under sunlight.

• Mutate easily, and each mutation triggers off anepidemic of respiratory disease.

• The name “coronavirus” refersto the protein moleculessurrounding the virus, makingit look like a crown (n.“corona”lat = crown).



The virus has a pattern of

proteins on its surface and

this pattern must “click” with

its hosts, just like the pieces

of a jigsaw puzzle. Only

when the pieces fit together

can the virus invade the cell.



Once inside the body, the

virus attaches to the cell wall

and injects itself into the

cell.



Its genetic material is

released into the human cell,

and it replicates.



The host cell bursts and

infection spreads. The fast-

mutating flu virus can

quickly become resistant to

drugs, making it difficult totreat.



Infectious Agent

a new and previously unrecognized coronavirus thathas been detected in patients with SARS



According to the WHO,as of May 16, 2003,

the total number of cases

of SARS worldwide is over 7000with about 600 deaths.(Death Rate = 7.8%)

At present, there are have been twelve cases of

SARS reported in the Philippines; two of these haddied; seven cases had been infected from one indexcase (AC). Four have already recovered.

Since May 7, 2003,the WHO has included the Philippines in the list of

areas with recent local transmission of SARS(i.e. with more than one generation of local probable

SARS cases).



China - 5013

Hong Kong – 1683/Macao - 1

Taiwan – 184

Thailand - 7

Vietnam - 63

Singapore - 205

TOTAL = 7193

SARS Cases: Western Pacific and South Asia

Malaysia - 7

Indonesia - 2

Australia - 6

Philippines - 10

South Korea – 2Mongolia - 9

New Zealand - 1

India - 1



China - 252

Hong Kong – 218/Macao - 0

Taiwan – 20

Thailand - 2

Vietnam - 5

Singapore - 28

TOTAL = 529

Malaysia - 2

Indonesia - 0

Australia - 0

Philippines - 2

South Korea – 0Mongolia - 0

SARS Deaths: Western Pacific and South Asia

New Zealand - 0

India - 0



How do we determine

who has SARS?1. Signs and Symptoms:

– cough

– difficulty of breathing

– fever (>38° C [100.4° F])2. Chest x-ray results:

– pneumonia or

– acute respiratory distress syndrome

3. History of travel– within 10 days of onset of symptoms from

countries with SARS cases

4. Close contact with persons diagnosedwith SARS



SARS transmission

• SARS can be transmitted fromperson to person by droplet

infection.– SARS cases, when they cough, canspread droplets with the infectiveorganism to a distance ofapproximately one meter or three

feet.• SARS can not be transmitted by

mosquitoes or animals; Ukay-ukay, meat, etc



How to Prevent Spread

1. Barring entry of sick passengersat port of exit from countries withSARS cases (i.e. China, HongKong, Singapore and Vietnam)

2. Health assessment through theHealth Check List and self-reporting among Philippineairports

3. Triage of cases through DOHhotline and referral to appropriatehospital facility



Advisory on Quarantine

• Persons symptomatic on arrival:– Direct to airport or maritime quarantine station

– Refer to hospitals (San Lazaro or RITM orregional hospitals)

• Persons asymptomatic on arrival:– If with contact with SARS case:

• Advise Voluntary Home Confinement

• Limit contact with members of the household

• Call DOH hotlines once signs and symptoms

indicative of SARS appear within 14 days afterarrival

– If without known contact with SARS case:• Call DOH hotlines once signs and symptoms

indicative of SARS appear within 14 days afterarrival



Personal Protective Equipment(PPE)

Cap N-95 Mask

GogglesGown

Gloves Shoe covers



N95

The “N” stands for

respirator filters that canbe used when no oil ispresent in thecontaminants.

The “95” means that the

product has been tested

and certified to have afilter efficiency level of95% or greater againstparticulate aerosols.



What are the limitationsof the N-95 respirator?

The N-95 respirator hasthe ability to filterparticles 1 micrometerwith a filter efficiency of

> 95%. If this respiratorbecomes wet, it is nolonger effective andmust be replaced. The N-95 is not intended for

protection from organicvapors, toxic gases, ortoxic particulates.



Key Points

• Designed to reduce the risk for occupational exposure to SARS

infection from both recognized and unrecognized sources of infection

• Wear disposable gowns, gloves and goggles for close patient contact

•Wash hands using liquid soap and water when leaving the anteroom

• Use an 70% alcohol-based hand rub solution after hand washing

• Wash hands when leaving the unit



DOH Operational Goals for SARS

1. Prevent/ Minimize entry of importedSARS cases

2. Prevent/ Minimize local transmission

3. Prevent/ Minimize mortality from SARS

4. Educate the Public on Effective SARSPrevention Behavior

5. Upgrade Facilities and Systems toachieve Goals 1-4.



Strategies and Actions Taken

• Prevention of Entry of SARS

• Hospital Preparedness

• Isolation and Containment

• Public Information

• Disease Surveillance

• Networking



Prevention of Entry

• Quarantine and Immigration

• Referral of suspect SARS casesto hospitals



Hospital Preparedness

• Isolation facilities (i.e. negativepressure rooms)

• Personal protective equipment(i.e. masks, gowns, caps, eyeshields, etc.)

• Laboratory/ autopsy capabilities• Ambulance transport



Clinical Management

• Finalization of the ConsensusGuideline in the Clinical Mgmt of

SARS• Triage flowchart

• Orientation of hospital personnel

• Briefings with WHO



Surveillance and Contact Tracing

• Strengthened Epidemiology and SurveillanceUnits

• Get referrals from quarantine, customs

immigration, etc.• Monitoring of contacts

• Triage thru SARS hotline

• Data management for Bureau of Quarantine

and International Health Surveillance• Case reports and worksheets from referral

hospitals and CHDs (Regional DOH offices)

• Formed Epidemiological response teams



Tarlac

Pangasinan Cordillera

Tarlac

Metro Manila

Pampanga

Travel: April 3 to 4, 2003

Canada

Narita, Japan

Philippines



Places Visited by ACPlaces Visited in

Pangasinan, Tarlac,

Pampanga and Baguio

Tarlac

Pangasinan Cordillera

Tarlac

Metro Manila

Pampanga

Metro Manila



Tarlac

PangasinanCordillera

Tarlac

Metro Manila

Pampanga

April 4, 2003 - 10:30 pm

April 5, 2003 - 5 am

April 6, 2003 - Morning

April 4 to 6, 2003

Source: NEC Operations Center



Tarlac

PangasinanCordillera

Tarlac

Metro Manila

Pampanga

April 7 to 11, 2003

April 7, 2003 – whole day

April 8, 2003 – whole day:San Juan; Pag-asa, QC

April 9, 2003 – Bgy SanVicente, Apalit, Pampanga

April 9, 2003 – Sta.Monica, Moncada, Tarlac

April 10, 2003 – Baguio City

April 11, 2003 – whole day

Source: NEC Operations Center



Contact Tracing for AC: Toronto

(NEC and Health Canada)

AC

B CA

A, B and C : Came from a visit from the Philippines; arrived inCanada on the first week of March; stopover in Hong Kong

Same doctor as that of ESS (BLD index

case) who died of SARS on April 1, 2003;

Admitted on April 4, 2003 at the Toronto

East General Hospital; Managed initially

with Ribavarine; diagnosis “unknown”;

with multiple organ system failure

A and AC had history of close contact (hugging) in the

apartment of AC when 1 was already sick

B and AC are housemates in Honey Drive, Toronto, Ontario

Both were quarantined on the 2nd week

of March; reportedly had low grade

fever; 2 is now on her 2 nd quarantine and

asymptomatic

C admitted on April 15, 2003 for Pneumonia

S M f B V



Spot Map of Bgy Vacante,Alcala, Pangasinan

1 2

3



What to remember?



Fight SARS with SARS-I• Strengthening immune system

• Avoiding contact with SARS cases

• Reporting to hospitals for respiratory

difficulties for those with history of contactwith a SARS case, and for survey symptomsand

• Stay calm because symptoms of SARS casesclosely resemble those of influenza and

asthma.• I believe and transmit accurate information



Do not worry:

If you did not travel to countries with

SARS cases in Februaryto May 16, 2003

If you did travel to countries with

SARS cases but did notcome near a known case of SARS

PUBLIC ADVISORY



For inquiries, call:

741-7048or

743-1937

Text Hotline:Text SARS (space) <Message>

then send to 2960

or for Information and Updates:

Text MED(space)SARSsend to

Globe 2333Smart 257



Thank you.

the war on sars

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