Clinical Guidelines for Management of Severe Acute Respiratory Syndrome [SARS]

Issued by the National Department of Health, 7^th May 2003

1. Introduction

Severe Acute Respiratory Syndrome (SARS) is a respiratory illness caused by a virus recently described in patients from Asia, North America and Europe. The World Health Organisation (WHO) is currently coordinating a global response to reported outbreaks of SARS. Cases have been reported from over 26 countries since 1^st November 2002. As of 7 May 2003, 6 727 suspect and probable cases of SARS with 478 deaths have been reported to WHO. Local transmission has so far been reported in Hong Kong Special Administrative Region of China (Hong Kong SAR), China mainland, Singapore, Taiwan (China), Canada (Toronto). Vietnam has been cleared off the list of affected countries after zero case report for 20 days (two incubation periods). On 7^th April South Africa reported the first probable case of SARS in Pretoria.

The National Department of Health in conjunction with the National Institute of Communicable Diseases (NICD) has compiled the clinical guidelines outlined below. Please note that these guidelines are subject to change as more is learnt about this condition.

2. Case Definition

Clinical cases suspected to be SARS need to meet the following criteria as recommended by the WHO and CDC interim case definition for SARS:

Respiratory illness of unknown etiology with onset since 1^st November 2002 and the following criteria:

• Pyrexia – measured temperature over 38° C.

• Clinical presentation – one or more findings of respiratory illness (e.g. cough, shortness of breath, difficulty breathing, hypoxia or radiographic findings of either pneumonia or acute respiratory distress syndrome). Other symptoms may include; chills, headache, malaise, myalgia etc.

• X-ray – focal, progressing to generalized airspace opacification and in some cases an ARDS.

• Contact history – travel within 10 days of onset of symptoms to an area with suspected or documented community transmission of SARS in Hong Kong Special Administrative Region, Guangdong Province in mainland China, Hanoi in Vietnam and Singapore (excluding areas with secondary cases limited to health care workers or direct household contacts).

or

• Close contact (defined as having cared for or having lived with or having had direct contact with respiratory secretions and/or body fluids of a patient) within 10 days of onset of symptoms with either a person with respiratory illness and travel to a SARS area or a person under investigation or suspected of having SARS.

3. Laboratory Investigations

The Provincial Communicable Disease Control Coordinator and provincial laboratories should ensure smooth collection and transportation of any specimen for investigation of SARS. Medical personnel must contact NICD (Contact numbers Dr L Blumberg 082 807 6770, Prof BD Schoub 082 908 8049 and Dr A Puren 082 908 8048) BEFORE sending specimens. For information on laboratory standard operation procedures (SOP) see laboratory guidelines for SARS.

3.1 Specimens Required:

1. Nasopharyngeal aspirates or bronchoalveolar lavage in viral transport medium. Procedure: pass a small catheter or feeding tube through the patient’s nose into the nasopharynx, instil 2-3ml of saline, and aspirate and place the contents directly into viral transport medium. Nasopharyngeal swabs do not provide adequate material, and therefore the results may not be reliable and throat swabs are totally unsuitable.

2. Infection control precautions must be followed during this procedure: gloves, gown, visor, and N-95 mask.

3. 5ml of clotted blood in a plain tube

3.2 Transport of Specimens

The specimens should be placed in a secondary container and surrounded by absorbent material in a polystyrene cold box. The details of the patient, the laboratory and the name and phone number of the doctor should be placed outside the box, and be easily accessible.

NB specimens cannot be processed unless there is prior consultation with the nicd.

4. General Management of SARS Cases

Patients MUST be isolated and barrier nursed with mask (ideally, N-95, HEPA mask – 8835 IF3) gown and glove precautions.

4.1 Infection Control - The Triage System

The infection control nurse should be overall overseer of infection control practices and should ensure that the following standard precautions are adhered to within the health facilities:

Standard Precautions

• Hand washing with soap is critical; before and after contact with any patient, after activities likely to cause contamination and after removing gloves.

• Isolation rooms/units and surfaces should be cleaned with broad-spectrum disinfectants of proven antiviral activity. The responsible staff should be provided with personal protective equipment (PPE).

• Disposable equipment should be used wherever possible in the management of patients with SARS and disposed of appropriately. If devices are to be re-used e.g., stethoscope, BP machine, they should be sterilized appropriately.

• Restriction of visitors/staff should be kept to a minimum and if granted permission to the isolation area, they should be issued with PPE (e.g., masks, gloves, goggles, disposable apron, footwear that can be decontaminated/disposed of) and be supervised.

• Linen from patients should be prepared on site (i.e. within the isolation rooms/unit) before laundry and put in biohazard bags.

4.1.1 Out Patient Department (OPD)

To facilitate early identification of patients who may have SARS at OPD the following guidelines should be adhered to:

• Targeted screening questions concerning fever, respiratory symptoms and recent travel to affected areas or contact with SARS patients should be provided to the infection control nurses, registration clerks/receptionists and Emergency Medical Services (EMS) staff.

• Suspected SARS cases on arrival at the OPD should be screened by infection control nurse in the waiting room and immediately isolated in a separate area/room to minimise transmission to others.

• The registration clerk/receptionist should immediately inform the infection control nurse should a suspected SARS case present at the registration desk, reception or waiting room (in absence of the infection control nurse).

• All the suspected cases should be evaluated in a separate assessment area to determine if they meet the case definition for suspected SARS.

• Those cases meeting SARS case definition must be admitted and managed in designated isolation rooms under strict barrier nursing. A mask (N-95) should be placed on the patient if possible.

• All Health care personnel including EMS personnel, receptionists/registration clerks should wear masks while taking care of patients with suspected SARS within OPD setting or transporting patients.

4.1.2 In-Patient Department

Infection control nurses should ensure that the following additional guidelines are adhered to in case a suspected SARS patient is admitted to the hospital:

• Standard precautions (e.g., hand hygiene); in addition to routine standard precautions, health care personnel should wear eye protection for all SARS patient contact.

• Contact precautions (e.g., use of gown and gloves for contact with the patient or their environment).

• Airborne precautions (e.g., an isolation room with negative pressure relative to the surrounding area and use of an N-95 filtering disposable respirator for persons entering the room).

• If airborne precautions cannot be fully implemented, patients should be placed in a private room, and all persons entering the room should wear N-95 respirators (if available).

• If N-95 respirators are not available for health care personnel, then surgical masks should be worn. Regardless of the availability of facilities for airborne precautions, standard and contact precautions should be implemented for all suspected SARS patients.

4.2 Clinical Management of Probable SARS Cases

All SARS cases must be hospitalised under isolation or cohort with other probable SARS cases and the following guidelines should be adhered to:

1. Take samples to exclude standard causes of pneumonia (including atypical causes), and send additional specimen to NICD for laboratory confirmation as indicated in Section 3.

2. Take samples for SARS investigation including white cell count, platelet count, creatinine phosphokinase, liver function tests, urea and electrolytes and C reactive protein.

3. At the time of admission the use of antibiotics for the treatment of community-acquired pneumonia with atypical cover is recommended.

4. Pay particular attention to therapies/interventions, which may cause aerolization such the use of nebullisers with a bronchodilator, chest physiotherapy, bronchoscopy, gastroscopy, and any procedure/intervention, which may disrupt the respiratory tract. Take the appropriate precautions if you feel that patients require the intervention/therapy.

5. A combination of Ribavirin with corticosteroids has been shown to be effective in most affected areas (e.g., China, Hong Kong Special Administrative Area).

4.3 Discharge and Follow-up Guidelines for SARS Patients;

4.3.1 Discharge Criteria

WHO recommends that prior to making a decision regarding discharge from hospital, the following criteria need to be considered:

1. Clinical symptoms/findings:

• Afebrile for 48 hours

• Resolving cough

2. Laboratory tests: if previously abnormal

• White cell count returning to normal

• Platelet count returning to normal

• Creatine phosphokinase returning to normal

• Liver function tests returning to normal

• Plasma sodium returning to normal

• C reactive protein returning to normal

3. Radiological findings:

• Improving chest x-ray changes

4.3.2 Follow-up Criteria for Convalescent Cases:

The Communicable Disease Control Coordinator should ensure that the guidelines for follow-up criteria for convalescent cases are observed as follows:

1. Communicable disease control Coordinators should ensure that discharged convalescent patients are monitored and record their temperature twice daily. If temperature rises to 38⁰C or above on two consecutive occasions patient should be re-admitted to the health care facility from which they were discharged.

2. Following discharge from hospital, convalescent cases should remain at home for 7 days. During this period they should stay indoors, keeping contact with others to a minimum.

3. After one week (7 days) a repeat chest x-ray, full blood count and any other blood tests that were previously abnormal should be conducted.

4. A decision should then be made on whether or not further confinement is required. Further confinement is recommended for the elderly, young (under fives) and those who are immunosuppressed. Subsequent follow-ups are recommended until the chest x-ray and patient’s health returns to normal.

5. As part of the follow-up, convalescent serology should be taken at 3 weeks after the date of disease onset and provided to the health care facility from which they were discharged.

6. Convalescent cases should be given clear instructions as to when to seek further medical care at the same health facility from which they were discharged.

7. The patient should be followed up by the health care worker from a facility from which they were discharged. Additionally, the clinician may decide that the patient needs to be followed up before one week elapses.

5. Monitoring of SARS Contacts

In order to minimise further transmission of the disease, the following contact tracing and monitoring guidelines should be adhered to:

1. A line listing of all SARS contacts with name, age, sex, address, telephone number/alternative number, next of kin, relationship with case and the occupation.

2. All contacts should remain at home and be monitored for signs/symptoms of SARS for a period of 14 days.

3. Contacts who develop signs and symptoms for SARS should be admitted for further management.

4. Contacts should be reminded of the need for careful personal and environmental hygiene (including hand washing with soap and water, unnecessary touching of face, mouth, nose should be avoided).

5. After 14 days the communicable disease control coordinator and his/her team will make a final assessment and decide on whether contact can resume normal life.

6. A documentation report of the cases and their contacts should be submitted to the Provincial Communicable Disease Control Coordinator who in turn should forward it to National DOH.