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Communicability. Patient factors Not infectious prior to symptoms Increases with increased severity of disease Increases post-onset symptoms (peak at day 7-10) Not infectious after recover No evidence of prolonged carriage or relapse Setting Duration, degree of contact

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communicability
Communicability
  • Patient factors
    • Not infectious prior to symptoms
    • Increases with increased severity of disease
    • Increases post-onset symptoms (peak at day 7-10)
    • Not infectious after recover
    • No evidence of prolonged carriage or relapse
  • Setting
    • Duration, degree of contact
    • Contact with airway (?contact with stool)
slide2

Communicability:

time in disease course

Peiris et al. Lancet, 2003

npa tns n 392
Onset (days)

0 – 2

3 – 5

6 – 8

9 – 11

12 – 14

15 – 17

18 – 20

21 – 23

% positive

31

43

60

57

59

35

18

13

NPA / TNS N=392

PCR: Time to positive

Stools N=50

%positive

0

57

86

90

100

33

60

43

Public Health - Hong Kong May 2003

communicability1
Communicability
  • Patient factors
    • Not infectious prior to symptoms
    • Increases with increased severity of disease
    • Increases post-onset symptoms (peak at day 7-10)
    • Not infectious after recover
    • No evidence of prolonged carriage or relapse
  • Setting
    • Duration, degree of contact
    • Contact with airway (?contact with stool)
exposure risk in icu
Exposure Risk in ICU
  • Loeb et al. (ICAAC 2003)
    • 8/32 entering room vs 0/11 others (P=0.09)
    • Risks: assisting with intubation RR=4.2 (1.6, 11)

suctioning prior to intubation RR=4.2 (1.6,11)

manipulation O2 mask RR=9.0 (1.3,65)

  • Scales et al. (ICAAC 2003)
    • 6/31 entering room vs. 1/38 others RR=8.8 (1,420)
    • Risks: in room for >4 hrs RR=24 (1.2,311)

present >30min with NIV RR=105 (3,3000)

sars control
SARS Control
  • Identification of cases
  • Isolation/quarantine
slide7

IP

Varia et al. CMAJ 2003

slide8

Toronto Area Probable and Suspect cases by source of infection

May 5, 2003

12

Travel

Non health care

Health care settings

10

8

Number of cases (P & S)

6

4

2

0

28-Apr-03

30-Apr-03

02-Apr-03

04-Apr-03

06-Apr-03

08-Apr-03

10-Apr-03

12-Apr-03

14-Apr-03

16-Apr-03

18-Apr-03

20-Apr-03

22-Apr-03

24-Apr-03

26-Apr-03

01-Mar-03

03-Mar-03

05-Mar-03

07-Mar-03

09-Mar-03

11-Mar-03

13-Mar-03

15-Mar-03

17-Mar-03

19-Mar-03

21-Mar-03

23-Mar-03

25-Mar-03

27-Mar-03

29-Mar-03

31-Mar-03

23-Feb-03

25-Feb-03

27-Feb-03

02-May-03

04-May-03

Date of onset of first symptoms

slide9

Grace Division

Emergency Department

March 16; 22:45-23:30

slide10

Reported cases of SARS in cases linked to the BLD group

March 20 to April 16, 2003

8

Health Care Worker

7

BLD

Family

6

5

Church

meetings

Funeral

4

Number of cases

Mr. S Jr.

3

2

1

0

19/03/03

21/03/03

23/03/03

25/03/03

27/03/03

29/03/03

31/03/03

02/04/03

04/04/03

06/04/03

08/04/03

10/04/03

12/04/03

14/04/03

16/04/03

Date of onset of symptoms

cluster of sars in hcws
Cluster of SARS in HCWs
  • 54 y.o.m. physician
    • April 1-2 saw 3 patients from BLD community
    • April 4-5 became ill
    • April 12 admitted to ICU
  • April 13
    • Intubated
    • RT-PCR positive in sputum and stool
  • April 15-21
    • 9 HCW become ill including 6 involved with intubation

MMWR 2003 May 16

effectiveness of precautions
Effectiveness of Precautions
  • Seto et al. Lancet 2003: Case (n=13)/Control (241)
    • Lower risk with handwashing OR 0.2 (.07,1)
    • Lower risk with gloves OR 0.5 (.14,1.6)
    • Lower risk with gown OR undef (P=.006)
    • Lower with masks OR 0.08 (.02,.33)
  • Loeb et al. ICAAC 2003: Cohort (43 nurses, 8 infected)
    • Lower risk with gloves OR 0.45 (.44, 4.5)
    • Lower risk with gown OR 0.36 (.10,1.2)
    • Lower risk with masks OR 0.23 (.07,.78)
number of sars hospitalization days mount sinai hospital
Number of SARs hospitalization days Mount Sinai Hospital

31 hours of unprotected exposure

(7 staff infected)

338 days of protected exposure

(?1 staff infected)

March

April

March

transmission in the setting of any precautions toronto
Transmission in the setting of any precautions, Toronto
  • Phase I - 260 patients
    • 22 HCW infected
    • intubation, cardiac arrest, “pre-intubation” care
  • Phase II – 129 patients
    • 3 HCW infected
    • cardiac arrest, bronchoscopy, “pre-intubation” care
differences between phase i and phase ii
Differences between Phase I and Phase II
  • HCW training and awareness
  • “Enhancements”
    • Double gloves, hair & foot covering, greens
  • Practice issues
    • Minimize time in room
    • Minimize contact with patient
    • Medical therapy to reduce cough/vomiting
    • Minimize procedures that increase risk of droplets
phase ii

Phase II

What went wrong?

impact on nygh
Impact on NYGH
  • HCWs 39
  • Patients 30
  • Visitors 18
conclusions
Conclusions
  • Disease driven by exposure
  • Transmission
    • Primarily in health care settings
    • Droplet/contact
    • Heterogeneous between patients
  • Control
    • Unrecognized patients are the most important problem
    • Precautions include not only barriers, but also practice
    • Compliance with precautions is critical
acknowledgements

Acknowledgements

Allison McGeer and Karen Green

The staff and patients of greater Toronto area hospitals and public health departments