Severe Acute Respiratory Syndrome SARS

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Severe Acute Respiratory Syndrome(SARS)

• Interim Australian Infection Control Guidelines
• Guidelines released by Commonwealth Department of
  Health and Aging
• 16 May 2003
• Presentation developed by Mary Smith
• Grampians Region Infection Control Group

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History

• The World Health Organisation (WHO) released a
  global health alert for authorities to be aware
  of a new atypical pneumonia (SARS) - 12 March
  2003
• Originally detected in Guangdong province in
  Southern China
• Reports of infection have come from Canada,
  China, Hong Kong, Taiwan, Singapore and Viet Nam
  SARS has spread to 25 countries around the world

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What Is SARS?

• A serious illness
• Atypical pneumonia caused by a novel coronavirus
  (WHO 16 April 2003)
• Spreads from person to person
• To people with close contact with infected person
• Incubation period 2 - 7 days

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Diagnosis

• SARS is currently a diagnosis of exclusion, the
  status of a reported case may change over time.
• Case definition based on clinical and
  epidemiological data are being supplemented by a
  number of lab tests
• Clinicians are advised that patients should not
  have their case definition category downgraded
  while awaiting results of laboratory testing or
  on the bases of negative results

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Symptoms of SARS

• High fever (over 38oC)
• Shortness of breath
• Dry cough
• With the fever-
• Bad headaches
• Confusion
• Generally sick
• Body aches and pains

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Disease Transmission

• Infectivity and aetiology of SARS is currently
  unknown
• Direct contact or close contact with symptomatic
  (fever or respiratory symptoms) individuals has
  resulted in transmission of SARS
• Droplet transmission ?
• Contact transmission ?
• Airborne transmission ?
• Indirect contact transmission (fomites) ?
• Oral faecal transmission ?

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Transmission

• Respiratory droplets
• direct contact (droplet into eye or mouth or on
  body)
• surfaces and fomites
• aerosol transmission (nebuliser in HK hospital)
• Virus also present in faeces, urine
• may explain Amoy Gardens outbreak
• Superspreaders
• symptomatic people (eg 108 particles per ml
  sputum)
• probably account for 80-90 of infections in
  hospital
• No good evidence for spread by people without
  symptoms Source SARS and Australia, Dr Richard
  Smallwood - Presentation 10 May 2003

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People at Risk of SARS

• Higher risk from
• Close contact with symptomatic person
• Family members
• Health care workers
• Lower risk from
• Contaminated environment
• Casual contacts
• Susceptibility factors
• Age, chronic disease, HIV(?)
• Reference SARS and Australia, Dr Richard
  Smallwood - Presentation 10 May 2003

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Interim Australian Infection Control Guidelines
for SARS 16 May 2003

•  
• These guidelines were prepared by a working
  party from the Department of Health and Ageing
  and the Communicable Disease Network of Australia
  (CDNA)
• As new information becomes available on the
  epidemiological and clinical characteristics of
  the disease the guidelines will be updated.

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Evidence Base 16 May 2003

• In the incubation period SARS is not transmitted
  from person to person
• In the prodromal period of fever and non specific
  symptoms infectivity starts
• When respiratory symptoms develop there is a
  higher level of infectivity
• High levels of transmission come from very severe
  cases, "super spreaders" who are extremely
  unwell.

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Evidence Base Contd

• Droplet and direct contact appear to be the
  predominant mode of transmission, although
  airborne and indirect contact through fomites and
  oral faecal transmission remain a possibility
• Introduction of infection control measures to
  prevent airborne, droplet and contact
  transmission has reduced transmission rates and
• Health care workers and close contacts of cases
  are at greatest risk.

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Triage Every Patient

• Targeted screening questions concerning
• Fever
• Respiratory symptoms
• Recent travel
• Should be included at triage or as soon as
  possible after patient arrival
• Triage should aim to rapidly divert those
  potential cases to a separate room for assessment
  in order to minimise transmission to others

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Triage Procedure if telephoned to notify
impending arrival

• If person being driven, instruct driver to come
  to triage desk and collect a mask to place on
  patient before they enter the facility
• If driving themselves, HCW must don appropriate
  PPE and meet patient outside the facility
• Nominate a suitable room to divert potential
  cases for further investigation

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Assessment

• DO NOT use aerosol generating procedures before
  they are assessed for possible SARS eg.
  nebulisers
• Place surgical masks on patients suspected to be
  cases of SARS while being transported to
  assessment area
• Take individual to separate area

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Assessment Process

• Staff should use
• Standard precautions (hand washing)
• Contact precautions (gloves, long sleeve gown and
  eyewear)
• Droplet precautions
• Airbourne precautions, including negative
  pressure isolation room where possible and use of
  P2 (N95) masks (where P2 masks are not available
  use a surgical mask)

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Screening Questions Every Patient

• Have you been to any of these (daily list
  available on www.who.int/csr/sarsareas/en/ ) in
  the last 10 days?
• Have you been in close contact with anyone with
  SARS?
• What areas have you been in and for how long?
• Have you had a fever?
• Do you have any of these symptoms, shortness of
  breath, cough or difficulty breathing?

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Affirmative Answer to Screening

• If the person has had contact with a SARS case
  or has been in a SARS affected area within 10
  days of onset of symptoms
• Measure patients temperature and any record any
  consumption of antipyretics within the last 4
  hours

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SUSPECT CASE

• If person
• Has been in a SARS affected area, AND has ONE of
• cough,
• shortness of breath OR
• difficulty breathing,
• AND their temperature is above 38oC

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PROBABLE CASE

• As for suspect case plus
• X-ray findings of pneumonia OR
• Patient died of Respiratory Distress Syndrome

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SUSPECT or PROBABLE CASE

• Infection control measures should include
• Standard precautions
• Contact precautions
• Droplet precautions
• Airborne precautions
• Small breaches in infection control (eg.
  adjusting masks, not cleaning contaminated
  fomites) may lead to transmission of the disease

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Accommodation

• Isolate and accommodate in descending order of
  preference
• Negative pressure room with door closed
• Single room with bathroom facilities
• Cohort placement in an area with independent,
  exhaust system and bathroom facilities

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Standard Precautions

• Work practices required for a basic level of
  infection control
• Hand hygiene
• Personal protective equipment
• Appropriate handling of sharps and waste
• Appropriate reprocessing of reusable items
• Use of aseptic technique
• Use of environmental controls
• To be used for all patients regardless of
  infectious status or perceived risk

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Hand Washing

• Wash hands before and after patient contact
• After activities likely to cause contamination
• After removing gloves
• Use alcohol based skin disinfectants if there is
  no obvious organic soiling

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Personal Protective Equipment

• PPE should be worn by all staff and visitors
  accessing the isolation unit
• Properly fitted P2 (N95) mask (respirator)
• Gloves
• Goggles, visor or face shield
• Long sleeve disposable gown

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Masks P2 (N95) Respirators

• Make sure mask is not damaged and the seal is in
  good condition
• Ensure all straps are in place and are not
  damaged
• Make sure metal nose clip (if applicable) is in
  place and functions correctly
• Ensure there is a good seal
• If P2 or equivalent masks are not available then
  surgical masks should be worn

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Fit Check - Mask

• Do not have contact with a SARS case until you
  have conducted a fit check
• This ensures that there are no air leaks around
  the mask
• No exhaust valve exhale
• Exhaust valve inhale
• Check for air leaks around the mask
• Discard mask after use

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Patient Education

• Patient should wear a surgical mask if anyone is
  in the room (if possible)
• Door of patients room should remain closed
• Staff and patient should be informed of this
• Restrict patient movement
• Patient must wear a mask if leaving the room

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Entering Leaving Room

• Place all PPE on before entering room
• On leaving
• Anteroom remove PPE in anteroom
• No anteroom exit room wearing PPE, place used
  PPE in pedal lift bin or covered laundry bin
  outside room
• Wash hands or use an alcohol rub immediately
  after removal of PPE

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Removal of PPE

• Remove in a way that does not allow transmission
  of SARS coronavirus
• Remove gloves first, do not touch skin
• Remove face/eye protection, wipe with alcohol
  wipe
• Remove gown, fold carefully with covered side in
  and place in covered linen bin
• Remove mask touching tapes only, discard
• Wash hands immediately or use an alcohol rub
  WASH VERY WELL

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Nursing Issues

• If possible, identify a member of staff who will
  have the sole role of observing the practice of
  others and provide feedback on infection control
• This person can aid in dressing and supervising
  the use of PPE
• Report any unprotected exposure to SARS cases

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Aerosol-generating Procedures

• Procedures that induce coughing can increase the
  likelihood of droplet nuclei being expelled into
  the air
• Aerosolized medication (eg. albuterol)
• Diagnostic sputum induction
• Bronchoscopy
• Airway suctioning
• Endotracheal intubation

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Precautions aerosol generating procedures

• Ensure patient has been evaluated for SARS
• Perform only when medically essential
• Apply standard, droplet, airborne and contact
  precautions
• Hand hygiene
• Respiratory protective devices with ? 95 filter
  efficiency
• Gown, gloves and eyewear

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Possible SARS Exposures

• Develop list of personnel who have contact with
  possible SARS patients (i.e. enter room,
  participate in care)
• Encourage reporting of unprotected exposures
• Monitor absenteeism for SARS-like illness

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Surveillance of Health Care Workers (HCWs)

• Keep a record of all unprotected exposures to
  SARS cases
• Quarantine HCW for 10 days if necessary (home or
  appropriate setting)
• All workers in SARS care team should have their
  temperature taken and recorded twice daily

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Staff Exclusion

• Exclude staff who are
• Immunosuppressed
• Older than 50 years
• Have an underlying illness, Hep B, diabetes
• Pregnant

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Patient Movement

• Avoid movement of patient outside the room if
  moved, patient should wear a surgical mask
• Do not allow non-essential staff (including
  students) on the unit/ward
• As few staff as possible should care for SARS
  patients

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Visitors

• Visitors must be kept to a minimum
• They must be issued with PPE, educated about its
  use and supervised
• Close contacts (eg. family members) of SARS
  patients are at risk of infection
• Close contacts with either fever or respiratory
  symptoms should not enter the HCF as visitors and
  should be educated about infection control
• A system for screening for symptoms in SARS close
  contacts should be in place

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Cleaning and Disinfection

• Early studies of SARS-coronavirus shows that if
  uninterrupted by cleaning or disinfectants, it
  can survive on surfaces in the environment such
  as stainless steel benches, plastic, wood, cotton
  for between 12 and 72 hours.
• However, the virus is not difficult to kill.

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Cleaning and Disinfection

• Heat (56oC) is very effective, so dishes, linen
  and other washable items can be disinfected by
  washing in hot water and detergent.
• Alcohol is effective. Alcohol can be found in
  alcohol rubs (for hands), alcohol impregnated
  wipes and swabs such as used to disinfect skin,
  and methylated spirits.

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Patient Equipment

• Use disposable equipment where ever possible
• Dispose of in clinical waste stream
• If reusable, reprocess in accordance with
  manufacturers instructions
• Commonly used items should not be removed from
  room - thermometers, stethoscopes, pens, etc

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Daily Cleaning

• Cleaning staff must wear PPE
• Frequently touch surfaces must be cleaned and
  disinfected when soiled and at least daily
• Bedrails, light switches, door knobs, hand
  basins, toilets and horizontal surfaces etc.
• Clean with neutral detergent and warm water then
  disinfect with bleach 500ppm or alcohol 60-70

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Cleaning After Discharge

• Postpone cleaning as long as practical
• Wear PPE when cleaning room
• Clean bedrails, light switches, door knobs, hand
  basins, toilets and horizontal surfaces etc. as
  for daily cleaning
• In addition, clean vertical surfaces, soiled area
  and floors
• Curtain dividers should be carefully removed and
  laundered
• Clean and disinfect cleaning equipment after use
  if not disposable

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Food Trays

• Tray to be removed from patients room by nurse
  and placed onto food trolley
• Tray removed by kitchen staff wearing utility
  gloves
• Tray , crockery and cutlery washed in dishwasher
  (thermally disinfected)
• Discard other items as normal

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Linen

• Linen should be transported from the patients
  room in leak-resistant, closed laundry bags
• No special requirements are needed for disposal
  or reprocessing of linen provided that the
  relevant Australian Standards are adhered to by
  the service provider.

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Waste Disposal

• Sharps to be dealt with in the normal manner
• All rubbish should be placed in clinical waste

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Specimen Collection

• Enclose specimens in leak proof containers with
  secure closures
• Clearly mark Suspected or probable SARS
• Do not use pneumatic tube systems risk of
  aerosols

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Vigilance Is Essential

• Targeted screening questions at triage are vital
• Early detection and strict adherence to airborne,
  droplet and contact precautions is essential in
  controlling the spread of SARS