Severe Acute Respiratory Syndrome (SARS): Lessons Learned for (Biological) Emergency Preparedness

1. Severe Acute Respiratory Syndrome (SARS):Lessons Learned for (Biological) Emergency Preparedness Jeffrey S. Duchin, M.D. Chief, Communicable Disease Control, Epidemiology, & Immunization Section Public Health - Seattle & King County Assistant Professor in Medicine, Division of Allergy and Infectious Diseases, University of Washington

2. Severe Acute Respiratory SyndromePublic Health - Seattle & King CountyChronology • 11 FEB: WHO “working to learn more” about an outbreak of severe respiratory illness in Guangdong Province, China ongoing since 16 November • Affected “hundreds” of persons • 30% of cases reportedly among health care workers • On 17 FEB: a 33 y.o. man who traveled with his family from Fujian Province in China died in a Hong Kong hospital. An 8 y.o. daughter died in Fujian, and an 9 y.o son was ill in Hong Kong. Influenza A (H5N1) isolated from the man and his son.

3. Severe Acute Respiratory SyndromePublic Health - Seattle & King CountyChronology

4. Severe Acute Respiratory SyndromePublic Health - Seattle & King CountyChronology • FEB 28th 2003: SARS identified in Vietnam after Dr. Carolo Urbani, epidemiologist, WHO Hanoi office, examined a patient with a severe atypical pneumonia of unknown etiology at the French Hospital in Hanoi • [17 March: First SARS investigation in King County] • 28 March: Chinese authorities conclude SARS outbreak is related to the outbreak in China • Report 792 suspected/probable cases in Guangdong province NOV 16, 2002-FEB 28, 2003 • 29 March: Dr. Carlo Urbani of the WHO dies of SARS

5. Severe Acute Respiratory SyndromePublic Health - Seattle & King CountyChronology • 11 July: 8,437 cases (813 deaths) reported to WHO from 29 countries: Country Cases Deaths China 5327 348 Hong Kong 1755 298 Taiwan 671 84 Canada 250 38 Singapore 206 32 USA 75 0 Viet Nam 63 5

6. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyQuestion at Annual Meeting of Prestigious Medical Subspecialty Society During SARS Outbreak • How many in the audience are clinical health care providers? • EVERYONE raises their hands • How many in the audience are part of the local public health system? • NO ONE raises their hand • Most clinicians (still) do not consider themselves part of the public health system

7. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountySARS Investigations • Approximately 140 investigations of possible SARS cases • 18 of the 140 initially classified as suspect SARS cases; subsequently reclassified to 7 cases after laboratory testing • Over 156 contact investigations related to suspect SARS cases • One suspect SARS case in a health care worker exposed to a suspect SARS patient • During March-April, public health received 104 to 232 calls per week (3-6 calls per hour) from the public and health care providers in King county

8. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountySARS Investigation Steps • Screen reports of febrile respiratory illness among travelers and their contacts for SARS case definition criteria • Interview the patient, family, contacts, physician(s) • Review medical records • Monitor cases under voluntary isolation until 10 days after resolution of fever and respiratory symptoms • Identify and monitor exposed health care workers

9. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountySARS Investigation Steps • Monitor other exposed close contacts (home, workplace, traveling companions, etc) • Follow-up SARS investigation and disease control measures if symptoms develop • Recommend appropriate isolation, infection control measures, lab testing and follow-up for cases and exposed persons • Determine case classification, report to state and CDC • Ensure submission of appropriate laboratory tests, track results • Requires tracking patients over time for acute and convalescent sera

10. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyLocal Public Health Impact • Approximately 16 FTE working full-time on SARS response • Medical epidemiologist, disease investigation staff, epidemiologists, public health nurses, program managers/administrators • Health educators, community outreach staff, communications team • Need dedicated staff to ensure appropriate diagnostic specimens obtained and processed correctly for laboratory testing • Administrative support

11. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyLocal Public Health Outbreak Response - Lessons • Rapidly identify and mobilize necessary resources (human and logistical) • Have epidemiology outbreak response plan • Clearly identify tasks, job assignments; communication, etc • Cross-train epidemiology and disease investigation staff • Catalogue all staff and their job skills • Plan to rapidly train staff recruited for emergency response

12. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyLocal Public Health Outbreak Response - Lessons • Implement incident command system early to engage resources • Senior administration • Technical program leads • Emergency manager • Procurement/grants & contracts • Communications team • Clinical services and nursing services • Environmental health • Legal advisor • Decide when to cease routine operations to divert resources towards outbreak response

13. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyLocal Public Health Outbreak Response - Lessons • Investigations are complicated, stressful and time consuming • Take into account when planning staffing needs and support services • Required “specialization” of epidemiology functions with designated staff for: • Phone inquiries • Screening and categorizing preliminary reports • Case investigations • Case classification • Contact tracing and follow-up • Monitoring of persons under quarantine and/or isolation • Case follow up • Hospital and health care worker investigations and monitoring of exposed persons

14. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyLocal Public Health Outbreak Response - Lessons • Hospital liaison extremely valuable • Designated field teams desirable for interviews, monitoring of cases, obtaining and/or transporting laboratory specimens • Specialized data collection tools and databases are needed • Must be developed rapidly, “on-the-fly” • Monitor cases through resolution of the communicable period • Contact surveillance • Tracking persons under isolation and quarantine • Tracking laboratory specimens • Advance preparation may be valuable

15. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyLocal Public Health Response - Lessons • High demand for information from the public and impacted organizations (business community, educational institutions), first responder agencies (police, fire, EMS) • Requires enhanced communications capacity • Phone banks and trained staff to answer calls • Hotline messages/web site • EOC • Health educators/spokespersons • Value of pre-existing relationships and communications channels

16. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountySurveillance/Case Identification - Lessons • Required “new approach” to management of febrile persons with respiratory symptoms in ambulatory care settings • Priority: Implement effective screening and triage procedures to rapidly identify potential cases in ambulatory care settings and hospitals • Required “systems” approach to surveillance at health care facilities rather than depending on specific individuals (physicians or ICNs)

17. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountySurveillance/Case Identification - Lessons • Implications for surveillance for other communicable diseases • Influenza • Measles • Pertussis • Varicella • Tuberculosis • Meningococcal disease • Smallpox • and others

18. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountySurveillance/Case Identification - Lessons • Benefit of on-site surveillance liaison at health care facilities • Health care facilities require functional systems and databases to: • Track exposures to both health care workers and patients • Monitor health care workers for development of symptoms • Track visitors to high-risk patients

19. Severe Acute Respiratory SyndromePublic Health - Seattle & King CountyCDC Surveillance Case Definition: Clinical Criteria • Asymptomatic or mild respiratory illness • Moderate respiratory illness • Temperature >100.4°F (>38° C) AND • One or more clinical findings of respiratory illness (e.g. cough, shortness of breath, difficulty breathing, hypoxia • Severe respiratory illness • Temperature >100.4°F (>38° C) AND • One or more clinical findings of respiratory illness (e.g. cough, shortness of breath, difficulty breathing, hypoxia) AND • Radiographic findings of either pneumonia or ARDS, or • Autopsy findings consistent with ARDS or pneumonia in the absence of an identifiable cause

20. Severe Acute Respiratory SyndromePublic Health - Seattle & King CountyCDC Surveillance Case Definition: Epidemiological Criteria • Travel (including transit in an airport) within 10 days of onset of symptoms to an area with current or recently documented or suspected community transmission of SARS • Areas with current documented or suspected community transmission of SARS according to CDC: • None currently listed

21. Severe Acute Respiratory SyndromePublic Health - Seattle & King CountyCDC Surveillance Case Definition: Epidemiological Criteria • Close contact within 10 days of onset of symptoms with a person known or suspected to have SARS infection. • Close contact is defined as having cared for or lived with a person known to have SARS, or having a high likelihood of direct contact with respiratory secretions and/or body fluids of a patient known to have SARS. • Examples of close contact include kissing or embracing, sharing eating or drinking utensils, close conversation (<3 feet), physical examination, and any other direct physical contact between persons. • Close contact does not include such activities such as walking by a person or sitting across a waiting room or office for a brief period of time.

22. Severe Acute Respiratory SyndromePublic Health - Seattle & King CountyCDC Surveillance Case Definition: Laboratory Criteria • Confirmed • Detection of antibody to SARS-CoV in specimens obtained during acute illness or >28 days after illness onset, or • Detection of SARS-CoV RNA by RT-PCR confirmed by a 2nd PCR assay by using a 2nd aliquot of specimen and different PCR primers, or • Isolation of SARS-CoV • Negative • Absence of antibody to SARS-CoV in convalescent serum obtained >28 days after symptom onset • Undetermined • Laboratory testing either not performed or incomplete

23. Severe Acute Respiratory SyndromePublic Health - Seattle & King CountyCDC Surveillance Case Definition: Case Classification • Probable case: • Meets clinical criteria for severe respiratory illness of unknown etiology with onset since February 1, 2003, and • Meets epidemiological criteria • Laboratory criteria confirmed, negative, or undetermined • Suspect Case: • Meets clinical criteria for moderate respiratory illness of unknown etiology with onset since February 1, 2003, and • Meets epidemiologic criteria • Laboratory criteria confirmed, negative, or undetermined

24. CDC: Interim Domestic Guidance on Persons Who May Have Been Exposed to Patients with Suspected Severe Acute Respiratory Syndrome (SARS), May 7, 2003

25. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountySurveillance/Case Identification - Lessons • Health care providers and clinicians need real time access to public health recommendations and guidelines • Current case definition • Recommendations for management of persons who may have been exposed to SARS: criteria for 72- and 144-hour isolation • Incorporate revisions to case definition and 72- and 144-hour isolation guidance as clinical and epidemiologial (exposure) criteria evolve • Systems used to communicate this information for SARS outbreak can serve as the basis for future emergencies or should be evaluated and improved to meet anticipated local needs

26. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountySurveillance/Case Identification - Lessons • Expectations of both public health staff and key partners should be realistic • Complicated, evolving, stratified case definition with clinical, epidemiological and laboratory criteria should be expected with new diseases • Anticipate “over sensitive” case definitions and corresponding implications for disease control and surveillance • May not be able to rely on laboratory testing to guide clinical and epidemiological/disease control activities • Highlights importance of accurate, thorough epidemiological information for case identification and management

27. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountySurveillance/Case Identification - Lessons • Optimal when clinicians know when to report and/or seek consultation with public health • Early: upon suspicion, not confirmation • Frequently most useful when patient still present • Requires easy access 24/7 to public health health system • Clinicians should know the infection control consultant and/or hospital epidemiologist and how to contact them 24/7 • Many clinicians do not have this information readily available • Having a designated public health assignee (outbreak liaison) at hospitals and other clinical sites can help facilitate surveillance, disease control activities and communication

29. Severe Acute Respiratory SyndromePublic Health - Seattle & King CountyInfection Control - Lessons • SARS disproportionately affected hospital staff (great feature for BT agent) compounding its impact on the health care system • Hospitals served as settings for amplification of transmission leading to community spread • Unrecognized cases played an important role in disease transmission in some locations • Infection control measures are the most important component of SARS management and prevention

30. Severe Acute Respiratory SyndromePublic Health - Seattle & King CountyInfection Control - Lessons • Need to rapidly identify potential cases of public health significance and implement appropriate disease control steps • Health care workers need to be knowledgeable about current and evolving infection control procedures and PPE guidelines • Guideline for Isolation Precautions in Hospitals and Guidelines for Infection Control in Health Care Personnel • Standard precautions • Contact precautions • Droplet precautions • Airborne precautions

31. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyInfection Control & Exposure Management - Lessons • Significant difference in infection control resources and capacity between hospitals and ambulatory care facilities • Need to enhance capacity of community clinics and ambulatory care facilities • Public health system must be prepared to respond when hospitals and the health care system become casualties

32. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyInfection Control & Exposure Management - Lessons • Other communicable disease requiring airborne precautions • Tuberculosis • Measles • Varicella (including disseminated zoster) • Smallpox

33. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyInfection Control & Exposure Management - Lessons • Other communicable diseases requiring droplet precautions • Invasive meningococcal disease • Mycoplasma pneumonia • Pertussis • Certain Group A streptococcal infections • Adenovirus • Influenza • Mumps • Rubella • Parvovirus B19 • Pneumonic plague • Smallpox

34. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyInfection Control & Exposure Management - Lessons • Other communicable disease requiring contact precautions • Multi-drug resistant bacterial infections • Certain enteric infections • Zoster and other skin infections • Viral hemorrhagic fever • Smallpox

35. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyRole of Clinicians in a Public Health Emergency • Need to have designated local clinical experts as spokespersons to communicate with the public (media) and other clinicians • Clinicians need to be knowledgeable about, and accurately disseminate, rapidly changing information • Case definition (clinical, epidemiological, laboratory criteria) • Infection control and exposure management recommendations for both the clinical and home settings • Travel advisories and alerts • Laboratory testing: appropriate samples, processing, interpretation • Treatment and prevention guidelines • Specialists should be engaged as local subject matter experts • Reinforce the public health message

36. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyCommunication - Lessons • CDC guidelines may not be sufficient to meet local needs • May need to develop more detailed local recommendations based on CDC guidance • Need for rapid dissemination of information, including the continually evolving guidelines and recommendations to: • Public health staff • Physicians and other health care professionals • Infection control practitioners • Emergency medical services • Air medical transport

37. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyCommunication - Lessons • Need for rapid dissemination of information, including the continually evolving guidelines and recommendations to: • Public • At-risk populations (i.e. departing and arriving travelers) • “Hard-to-reach” populations (non-English speaking, homeless, institutionalized, etc) • Businesses, organizations, schools • Media • Need robust health education capacity for clinical and non-clinical audiences

38. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyCommunication - Lessons • Special challenge reaching non-English speaking populations • Urgent need for translations: authoritative central source • Need to identify and train bilingual public health staff for outreach work • Found that many community members were not aware of public health resources such as web site or telephone hotline • Some health care providers not “plugged in” to public health communication system or resources including CDC • Need to respond aggressively to misinformation leading to prejudice and discrimination

39. Public Health - Seattle & King CountySevere Acute Respiratory SyndromeCommunication - Lessons • Information to hospitals, health care providers, the public • Health advisories by broadcast fax and listserv • Conference calls with hospital infection control teams • SARS information signs for King County clinical facilities in English, Chinese, Vietnamese, and Spanish • Community outreach staff: Chinese, Vietnamese, English • Information on hospital association and public health website • In-person education/training for clinicians • 24/7 availability to clinicians • Media interviews

40. Severe Acute Respiratory SyndromePublic Health - Seattle & King CountyIsolation & Quarantine Isolation • Restriction of movement and/or separation of persons ill with a contagious disease • Usually in a hospital setting, but can also be at home or in a dedicated isolation facility Quarantine • Restriction of movement and/or separation of well persons presumed exposed to a contagious disease • Usually at home, but can be in a dedicated quarantine facility • Individual(s) or community/population level Isolation & quarantine • Measures usually voluntary, but can be mandatory. • Legal quarantine authority exists at federal, state and local levels and covers isolation” and “quarantine”

41. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyIsolation and Quarantine - Lessons • Isolation & quarantine • Rely on patients to comply with voluntary isolation request • Issued voluntary isolation request letter to all SARS cases • Have template letters available • Critical importance of patient education by physician regarding need for compliance with isolation and with infection control recommendations • Requires access to current versions of isolation requests, printed instructions and guidelines, Q & A, etc., for patients and exposed persons

42. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountyIsolation and Quarantine - Lessons • Be prepared to implement widespread use of isolation and quarantine • Need to establish efficient procedures for ordering mandatory isolation/quarantine, including legal process and tracking system • Need to develop procedures for enforcement of isolation and quarantine orders • Plan for management & supervision of persons under quarantine • Teams to monitor and provide for the needs of persons under isolation and quarantine and their dependants, including social and psychological support • Plan for dedicated isolation & quarantine facility

43. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountySARS and Biological Disaster/Terrorism Preparedness The influenza pandemic of 1918-19 killed more humans than any other disease in a period of similar duration in the history of the world. Alfred W. Crosby America’s Forgotten Pandemic - The Influenza of 1918 Cambridge University Press, 1989

44. SARS and Biological Disaster/Terrorism PreparednessDeaths By Week due to Pneumonia & InfluenzaOctober, 1918 through March, 1919 - Philadelphia, PA Population: 1,761,371 Total deaths: 15,785

45. Severe Acute Respiratory SyndromePublic Health – Seattle & King CountySummary • SARS is a local problem, as are all outbreaks and emergencies • Lessons learned during the SARS outbreak are applicable to other biological emergencies and outbreaks, including smallpox • Clinicians are on the front line as public health responders: we need to acknowledge it even if they don’t • Individual patient care and the public health response are closely related and inter-dependant • Overall success containing SARS (and other emergencies) measured by sum of local successes and failures • The worst may be yet to come

46. Severe Acute Respiratory SyndromePublic Health – Seattle & King County

47. Questions?

48. Public Health - Seattle & King CountyCommunicable Disease Control, Epidemiology & Immunization Section Contact us for additional information and to report suspected cases. Communicable disease report/consultation line and after-hours emergencies: 206-296-4774 Web Site: http://www.metrokc.gov/health/