SARS Outbreak in SARS Outbreak in Hong KongHong Kong

Professor Peter CameronProfessor Peter CameronPreviouslyPreviously

COS Prince of Wales HospitalCOS Prince of Wales HospitalChinese University of Hong KongChinese University of Hong Kong

BackgroundBackground

• Aware of Reports of Atypical Aware of Reports of Atypical Pneumonia in GuangzhouPneumonia in Guangzhou

• Reported 305 cases and 5 deaths and Reported 305 cases and 5 deaths and then information ceasedthen information ceased

• Thought that it was probably worseThought that it was probably worse• ? Chlamydia? Chlamydia• A couple of unusual cases admitted to A couple of unusual cases admitted to

HK hospitals – died, no secondary HK hospitals – died, no secondary spreadspread

Index Case Prince of Index Case Prince of WalesWales

• Admitted Ward 8A, March 4, 2003Admitted Ward 8A, March 4, 2003• 26 yo ethnic Chinese, symptoms of high 26 yo ethnic Chinese, symptoms of high

fever, myalgia, and coughfever, myalgia, and cough• One ED attendance 4 days previously for One ED attendance 4 days previously for

fever and myalgiafever and myalgia• Diagnosed with pneumonia and treated Diagnosed with pneumonia and treated

with augmentin and clarithromycinwith augmentin and clarithromycin• Improved over one weekImproved over one week• No unusual featuresNo unusual features

Recognition of OutbreakRecognition of Outbreak

• Staff of 8A noticed a number of medical Staff of 8A noticed a number of medical and Nursing staff sickand Nursing staff sick

• ? Influenza – Discussion regarding isolation? Influenza – Discussion regarding isolation– Area with separate ventilation, entry from main Area with separate ventilation, entry from main

wardswards– ? ED Observation Ward? ED Observation Ward– Discussion with CEO, Prof Medicine and EDDiscussion with CEO, Prof Medicine and ED

• Establish FactsEstablish Facts– 15 medical and 15 Nursing staff sick15 medical and 15 Nursing staff sick– 5 ED docs and 3 nurses5 ED docs and 3 nurses– Other pts and visitorsOther pts and visitors– Medical studentsMedical students

ResponseResponse

• Symptomatic staff isolated to ED Symptomatic staff isolated to ED Observation WardObservation Ward

• Not all staff compliedNot all staff complied– ?over reacting?over reacting

• CEO called council of war next morning CEO called council of war next morning of service chiefs – then twice dailyof service chiefs – then twice daily

• Hospital continued normal services Hospital continued normal services initiallyinitially

• 2-3 days to recognise internally the 2-3 days to recognise internally the extent of the problemextent of the problem

ResponseResponse

• Community aware that PWH had a Community aware that PWH had a problem within 2 daysproblem within 2 days

• Thought to be internal and Thought to be internal and government supported this viewgovernment supported this view

• Did not ban visitors initiallyDid not ban visitors initially• Balance between Balance between

panic/service/managing an outbreakpanic/service/managing an outbreak

Staff getting sickerStaff getting sicker

EDED

ScreeningScreening

WardWard

UnknownUnknown

• Nature of organismNature of organism• Mode of spreadMode of spread• Extent of spreadExtent of spread• OutcomeOutcome• Likely epidemiologyLikely epidemiology

– ?world pandemic?world pandemic

QuarantineQuarantine

• Intense lobbying by senior cliniciansIntense lobbying by senior clinicians• Staff afraid to go home at nightStaff afraid to go home at night• VisitorsVisitors• Patients Patients

– ElectiveElective– SpecialistSpecialist– EmergencyEmergency

• Possible casesPossible cases– Home vs ward isolationHome vs ward isolation– Screening proceduresScreening procedures

Reported Clinical Reported Clinical FeaturesFeatures

(Inpatients)(Inpatients)• Incubation period – 2-7 days but ?16 daysIncubation period – 2-7 days but ?16 days• SymptomsSymptoms

– Fever 100%Fever 100%– Chills/rigors 73.2%Chills/rigors 73.2%– Myalgia 61%Myalgia 61%– Cough 57%Cough 57%– Headache 56%Headache 56%– Dizziness 43%Dizziness 43%

• Also N&V, diarrhea, abdo pain, coryza, sore thoat Also N&V, diarrhea, abdo pain, coryza, sore thoat ~20%~20%

Initial Symptoms at a Initial Symptoms at a Screening ClinicScreening Clinic

SARS -SARS -SARS+SARS+

• FeverFever 37%37% 81%81%• ChillsChills 21%21% 52%52%• MalaiseMalaise 20%20% 34%34%• MyalgiaMyalgia 12%12% 27%27%• RigorRigor 4%4% 12%12%• CoughCough 72%72% 64%64%• URIURI neg predictorneg predictor• LOA/Vomiting/DiarrhoeaLOA/Vomiting/Diarrhoea Pos PredictorsPos Predictors

CT ChangesCT Changes

EpidemiologyEpidemiology

• Contact tracingContact tracing• Health department processes not Health department processes not

adequateadequate• Expertise?Expertise?

Epidemiology Amoy Epidemiology Amoy GardensGardens

Graphic of epidemiologyGraphic of epidemiology

Infection controlInfection control

• Droplet spreadDroplet spread– Mask, glove, cap and gownMask, glove, cap and gown– Surfaces/fomitesSurfaces/fomites– Hood/visor for proceduresHood/visor for procedures– Viral filtersViral filters

• Other modes of spread?Other modes of spread?– Definite evidence of faecal/urine viral loadsDefinite evidence of faecal/urine viral loads– No evidence of airborne – negative pressure No evidence of airborne – negative pressure

unnecessaryunnecessary

Airborne SpreadAirborne Spread

• NebulisersNebulisers• Non Invasive VentilationNon Invasive Ventilation• Continuum between aerosol and Continuum between aerosol and

dropletdroplet

EngineeringEngineering

• VentilationVentilation• Toilet layoutToilet layout• Sewage Sewage • Negative pressure roomsNegative pressure rooms• Ward layoutsWard layouts

TreatmentTreatment

• Empiric treatmentEmpiric treatment– Antivirals - ribavirinAntivirals - ribavirin– SteroidsSteroids– Cytokine inhibitorsCytokine inhibitors– Convalescent serumConvalescent serum– Traditional chinese medicineTraditional chinese medicine

• Ethics?Ethics?• Political pressurePolitical pressure

Staff MoraleStaff Morale

• Service chiefs – daily updatesService chiefs – daily updates• Staff forum dailyStaff forum daily• Web site updatesWeb site updates• Daily ward round by senior staffDaily ward round by senior staff

• CEO of hospital and Hospital Authority CEO of hospital and Hospital Authority contracted diseasecontracted disease

• Face to face meetings – danger of cross Face to face meetings – danger of cross infectioninfection

• HKSAR CEO perceived badly for not being on HKSAR CEO perceived badly for not being on sitesite

FamiliesFamilies

• Important aspect of staff moraleImportant aspect of staff morale• Should staff stay in quarters – Should staff stay in quarters –

increased risk for staffincreased risk for staff• Isolation of staff from familiesIsolation of staff from families

– Possibility of monthsPossibility of months– Send family away – increased risk to Send family away – increased risk to

other communitiesother communities– If staff go home – what precautions If staff go home – what precautions

needed?needed?

Outcomes in PWHOutcomes in PWH

• 20-30% of all pts in ICU20-30% of all pts in ICU• No nursing or medical staff at PWH No nursing or medical staff at PWH

dieddied• >100 staff and med students affected>100 staff and med students affected• Initial mortality ~5% but case fatality Initial mortality ~5% but case fatality

rate >10%rate >10%• In elderly >50%In elderly >50%• Long Term?Long Term?

– Pulmonary fibrosisPulmonary fibrosis

Outcomes in HKOutcomes in HK

• ~ 1700 cases~ 1700 cases• ~300 deaths~300 deaths• Outbreak over in less than 3 monthsOutbreak over in less than 3 months• ~25% cases staff~25% cases staff

Graph of case fatalityGraph of case fatality

Community ResponseCommunity Response

• HospitalsHospitals– Initially PWHInitially PWH– Other hospitals became involvedOther hospitals became involved– Infectious disease hospitalInfectious disease hospital

• OverloadedOverloaded

Community ResponseCommunity Response

• schoolsschools• Tourist and economyTourist and economy• GovermentGoverment

Schools?Schools?

Tourists + economy?Tourists + economy?

Street sweepingStreet sweeping

Living Life with a maskLiving Life with a mask

Governments?Governments?

Wu and wenWu and wen

MicrobiologyMicrobiology

• Uncertainty about organismUncertainty about organism• Tests actually caused problemsTests actually caused problems

– Not properly trialled for accuracyNot properly trialled for accuracy

Serologic confirmation of Serologic confirmation of casescases

• Coronavirus confirmed in virtually Coronavirus confirmed in virtually all those with classic courseall those with classic course

• Very few cases with no symptoms Very few cases with no symptoms and CoV serologyand CoV serology

• Reason for immunity?Reason for immunity?– Mucosal barrierMucosal barrier– IgAIgA

Lessons LearntLessons Learnt

• Politics of Infectious disease uglyPolitics of Infectious disease ugly• Little is known about infectious diseaseLittle is known about infectious disease• Basic infection control worksBasic infection control works• Basic Infection control is not done wellBasic Infection control is not done well• Hospital workers are at riskHospital workers are at risk• Authorities are always behind in Authorities are always behind in

managing disastersmanaging disasters• Don’t try to predict natureDon’t try to predict nature• Life Returns to normal quicklyLife Returns to normal quickly

Life Returns to normal Life Returns to normal quicklyquickly

Picture of front linePicture of front line

VenepunctureVenepuncture

Mona lisa with maskMona lisa with mask