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Severe Acute Respiratory Syndrome (SARS). GP seminars. SARS. Mid November 2002 Guangdong Province, China “ outbreak of atypical pneumonia” 11 February 2003 WHO informed 305 cases (5 deaths) 30% in health care workers July 2003 8,437 probable cases from 32 countries

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Mid November2002

  • Guangdong Province, China
  • “ outbreak of atypical pneumonia”

11 February 2003

  • WHO informed
  • 305 cases (5 deaths)
  • 30% in health care workers

July 2003

  • 8,437 probable cases from 32 countries
  • major foci in China, SE Asia and Toronto
  • 4 in UK (none from NI)
hasn t sars been eliminated
Hasn’t SARS been eliminated?
  • On 5 July WHO said outbreak was contained.
  • BUT WHO have warned it might return and urged planning for it.
  • Majority of experts think it might return.
  • Planning for it remains a high government priority.
why might it return
Why might it return?
  • Other new and poorly understood viruses (e.g. Ebola and Marburg) periodically surface to cause outbreaks then disappear again.
  • This is a respiratory illness – these are usually worse in winter and disappear in summer.
  • We don’t know how it appeared or where from – so can’t be confident of stopping it from doing so again.
sars coronavirus sars cov
SARS coronavirus (SARS CoV)
  • New member of coronavirus family
  • found in wild animals in China
  • incubation period 2-7 (max 10) days
  • viral shedding peaks 6-10 days after onset of symptoms
  • droplet spread
  • less infectious than influenza
  • no vaccine available
sars cov infectivity
SARS CoV - infectivity
  • Most transmission via close contact with a symptomatic person via large respiratory droplets. Transmission by fomites possible.
  • Those severely ill more infectious (attack rate of >50% in some hospital staff)
  • Infectivity increases during second week of illness
  • Transmission from an asymptomatic person unlikely
  • May remain infectious up to 10 days once afebrile

SARS CoV - infectivity

(MMWR 2003:52 (18): 405-11)

clinical symptoms at presentation in

Lee et al.


Peiris et al.


Donnelly et al. n>1250

Booth et al. n=144


Chills or rigors




Runny Nose

Sore Throat

Shortness of breath











































Clinical symptoms at presentation (in %)

* chills

clinical course triphasic
Clinical course - triphasic

Week 1

  • fever, myalgia, systemic symptoms that improve after a few days

Week 2

  • Fever returns, oxygen desaturation, CXR worsens


  • 20% get ARDS needing ventilation

Peiris - Lancet 2003b; 361: 1767-72

sars morbidity
SARS - morbidity
  • Most cases are in healthcare workers caring for SARS patients and close family members of SARS patients
  • overall mortality 15%
  • mortality increases with age

(> 65 years - 50% mortality)

  • children seem to develop mild illness
clinical case definition
Clinical case definition

A respiratory illness severe enough for hospitalisation and include a history of:

  • Fever (> 380C)


  • one or more symptoms of respiratory tract illness (cough, difficulty breathing, SOB)


  • CXR of lung infiltrates consistent with pneumonia or RDS or PM consistent with pneumonia or RDS without an identifiable cause


  • No alternative diagnosis to fully explain the illness

CDSC Colindale 15 Aug 03

sars diagnosis
SARS diagnosis
  • Clinical findings of an atypical pneumonia not attributed to other causes
  • exposure to suspect/probable SARS
  • or exposure to their respiratory secretions or body
sars laboratory diagnosis
SARS laboratory diagnosis
  • PCR positive for SARS CoV using validated methods on at least 2 different clinical specimens
  • Seroconversion (gold standard)

(negative antibody test on acute specimen followed by positive test on convalescent sera or > 4 rise in antibody titre between acute and convalescent sera)

sars treatment
SARS - treatment
  • Supportive
  • avoid aerosol inducing interventions
  • evidence base for anti-viral drugs lacking
  • steroids may be helpful
ni sars contingency plan levels of response
NI SARS contingency plan:levels of response

0: initial preparedness (no active cases in UK/Ireland)

1: (A) sporadic imported case(s) to GB/Ireland

1: (B) sporadic imported case(s) to NI

2: intra hospital transmission and/or limited community transmission within definable groups

3: extensive community transmission

4: post outbreak and de-escalation of outbreak response

sars preparedness
SARS preparedness

NI Taskforce and subgroups



Port Health



Primary &

Community Care



Human Resources

key points in control of any communicable disease
Key points in control of any communicable disease
  • early case detection
  • swift isolation
  • thorough control of infection measures
  • vigorous identification and management of close contacts by home confinement
  • public information for those at risk of infection
  • education of health care professionals
personal protective equipment
Personal protective equipment
  • Masks
  • Waterproof long sleeved gowns
  • Gloves
  • Goggles
  • Centrally sourced and distributed
masks and respirators
Masks and Respirators.
  • Masks
    • Main purpose – help prevent particles (droplets) being expelled into environment by wearer
    • Resistant to fluids – help protect wearer from splashes of blood or other potentially infected substances
    • Not necessarily designed for filtration efficiency, or to seal tightly to the face
    • Protection to wearer is therefore limited.
masks and respirators24
Masks and Respirators.
  • Respirators
    • Intended to help reduce wearer’s exposure to airborne particles
    • Made to defined standards
    • When worn correctly – seal firmly to face – reducing risk of leakage
    • Some have one way valves – would be useless for putting on infected person
what is the correct way to use a mask

What is the correct way to use a mask?

First – How not to do it!

what is the correct way to use a mask29
What is the correct way to use a mask?
  • Should fit snugly over mouth, nose and chin
  • Coloured side out
  • Metal strip at top – mould to bridge of nose
  • If in healthcare setting dispose of as clinical waste
  • In home – patients should place in plastic bag then in domestic waste
  • Hands must always be washed following removal. (Remove handling straps only – avoid contact with face part)
what is the correct way to use a respirator
What is the correct way to use a respirator?
  • Each type may differ - So always read the accompanying instructions.
  • Do a fit check or user seal check every time a respirator is put on – Fit is critically important.
  • It must seal tightly to the face – needs clean-shaven skin – beards, long moustaches and stubble may cause leaks.
  • Go to a safe area to change it if: breathing becomes difficult; it becomes damage, distorted, or splashed by body fluids; or a proper face fit cannot be maintained.
when should masks or respirators be used
When should masks or respirators be used?
  • Healthcare workers should use respirators for any contact with suspected or probable cases of SARS
  • A mask should be used only if a respirator is not available – better than no protection
  • Patients should use a mask while symptomatic whether in hospital, at home or in transit.
  • But wearing a mask or respirator is not a guarantee of protection against SARS.
other aspects of infection control
Other aspects of infection control
  • Hand hygiene – essential
  • Gloves
  • Fluid resistant long sleeve gown
  • Eye protection (visor best)
  • Environmental & equipment decontamination.
putting on ppe
Putting on PPE
  • Put on in following order:
    • Respirator
    • Eyewear
    • Gown
    • Gloves – ensuring wrists of gloves are pulled up over sleeves of gown.
removal of ppe
Removal of PPE
  • Crucial that PPE is removed without accidental contamination of facial skin or mucous membranes.
  • Remove PPE in following order:
    • Gown
    • Gloves
    • Wash hands
    • Eye protection
    • Mask
    • Wash hands
importance of infection control procedures
Importance of Infection Control Procedures
  • Detailed aspects of infection control are very important e.g. exactly how to remove a gown, correct hand washing technique etc.
  • A video describing all this will be produced and widely distributed – Please make sure you and all relevant colleagues watch it.
  • Correct use of all infection control procedures will provide very good protection against SARS.
likely pathway
Likely pathway

Sporadic cases

  • GP - A&E - designated SARS facility

Extensive community transmission

  • Home versus hospital management


scenario 1 unannounced presentation
Scenario 1:Unannounced presentation
  • Isolate patient
  • Mask on patient
  • Assessment – wear your PPE
        • Case definition/ clinical status
        • Refer to A&E
  • Register of staff contacts
  • Report to public health
  • Decontamination
scenario 2 announced patient at home
Scenario 2:Announced (patient at home)
  • Triage by telephone
  • Home visit or refer direct to hospital
  • Refer to A&E
  • Report to public health
  • Advise family
implications for primary care
Implications for primary care

Get prepared now!

  • Develop a practice protocol
  • Develop a patient pathway (receptionist GP)
  • Train all staff
  • Know PPE procedures*
  • Plan decontamination systems (include nebulisers)*
  • Identify a dedicated room.

Situation has potential to change rapidly!

what resources are will be available
What resources are/ will be available?
  • Advice on decontamination
  • Referral algorithms (?designated hospitals)
  • Training materials
  • CCDC/ on-call public health
  • Updated DHSSPS communications
  • Websites: