SARS Outbreak in Hong Kong

1. SARS Outbreak in Hong Kong Professor Peter Cameron Previously COS Prince of Wales Hospital Chinese University of Hong Kong

2. Background • Aware of Reports of Atypical Pneumonia in Guangzhou • Reported 305 cases and 5 deaths and then information ceased • Thought that it was probably worse • ? Chlamydia • A couple of unusual cases admitted to HK hospitals – died, no secondary spread

3. Index Case Prince of Wales • Admitted Ward 8A, March 4, 2003 • 26 yo ethnic Chinese, symptoms of high fever, myalgia, and cough • One ED attendance 4 days previously for fever and myalgia • Diagnosed with pneumonia and treated with augmentin and clarithromycin • Improved over one week • No unusual features

4. Recognition of Outbreak • Staff of 8A noticed a number of medical and Nursing staff sick • ? Influenza – Discussion regarding isolation • Area with separate ventilation, entry from main wards • ? ED Observation Ward • Discussion with CEO, Prof Medicine and ED • Establish Facts • 15 medical and 15 Nursing staff sick • 5 ED docs and 3 nurses • Other pts and visitors • Medical students

5. Response • Symptomatic staff isolated to ED Observation Ward • Not all staff complied • ?over reacting • CEO called council of war next morning of service chiefs – then twice daily • Hospital continued normal services initially • 2-3 days to recognise internally the extent of the problem

6. Response • Community aware that PWH had a problem within 2 days • Thought to be internal and government supported this view • Did not ban visitors initially • Balance between panic/service/managing an outbreak

7. Staff getting sicker

8. ED

9. Screening

10. Ward

11. Unknown • Nature of organism • Mode of spread • Extent of spread • Outcome • Likely epidemiology • ?world pandemic

12. Quarantine • Intense lobbying by senior clinicians • Staff afraid to go home at night • Visitors • Patients • Elective • Specialist • Emergency • Possible cases • Home vs ward isolation • Screening procedures

13. Reported Clinical Features(Inpatients) • Incubation period – 2-7 days but ?16 days • Symptoms • Fever 100% • Chills/rigors 73.2% • Myalgia 61% • Cough 57% • Headache 56% • Dizziness 43% • Also N&V, diarrhea, abdo pain, coryza, sore thoat ~20%

14. Initial Symptoms at a Screening Clinic SARS - SARS+ • Fever 37% 81% • Chills 21% 52% • Malaise 20% 34% • Myalgia 12% 27% • Rigor 4% 12% • Cough 72% 64% • URI neg predictor • LOA/Vomiting/Diarrhoea Pos Predictors

15. CT Changes

16. Epidemiology • Contact tracing • Health department processes not adequate • Expertise?

17. Epidemiology Amoy Gardens

18. Graphic of epidemiology

19. Infection control • Droplet spread • Mask, glove, cap and gown • Surfaces/fomites • Hood/visor for procedures • Viral filters • Other modes of spread? • Definite evidence of faecal/urine viral loads • No evidence of airborne – negative pressure unnecessary

20. Airborne Spread • Nebulisers • Non Invasive Ventilation • Continuum between aerosol and droplet

21. Engineering • Ventilation • Toilet layout • Sewage • Negative pressure rooms • Ward layouts

22. Treatment • Empiric treatment • Antivirals - ribavirin • Steroids • Cytokine inhibitors • Convalescent serum • Traditional chinese medicine • Ethics? • Political pressure

23. Staff Morale • Service chiefs – daily updates • Staff forum daily • Web site updates • Daily ward round by senior staff • CEO of hospital and Hospital Authority contracted disease • Face to face meetings – danger of cross infection • HKSAR CEO perceived badly for not being on site

24. Families • Important aspect of staff morale • Should staff stay in quarters – increased risk for staff • Isolation of staff from families • Possibility of months • Send family away – increased risk to other communities • If staff go home – what precautions needed?

25. Outcomes in PWH • 20-30% of all pts in ICU • No nursing or medical staff at PWH died • >100 staff and med students affected • Initial mortality ~5% but case fatality rate >10% • In elderly >50% • Long Term? • Pulmonary fibrosis

26. Outcomes in HK • ~ 1700 cases • ~300 deaths • Outbreak over in less than 3 months • ~25% cases staff

27. Graph of case fatality

28. Community Response • Hospitals • Initially PWH • Other hospitals became involved • Infectious disease hospital • Overloaded

29. Community Response • schools • Tourist and economy • Goverment

30. Schools?

31. Tourists + economy?

32. Street sweeping

33. Living Life with a mask

34. Governments?

35. Wu and wen

36. Microbiology • Uncertainty about organism • Tests actually caused problems • Not properly trialled for accuracy

37. Serologic confirmation of cases • Coronavirus confirmed in virtually all those with classic course • Very few cases with no symptoms and CoV serology • Reason for immunity? • Mucosal barrier • IgA

38. Lessons Learnt • Politics of Infectious disease ugly • Little is known about infectious disease • Basic infection control works • Basic Infection control is not done well • Hospital workers are at risk • Authorities are always behind in managing disasters • Don’t try to predict nature • Life Returns to normal quickly

39. Life Returns to normal quickly

40. Picture of front line

41. Venepuncture

42. Mona lisa with mask