Severe Acute Respiratory Syndrome ( SARS )

Severe Acute Respiratory Syndrome ( SARS )

Dr. Mohammad Rahim Kadivar Pediatrics Infections Specialist Shiraz University of Medical Sciences Slides Designer: Dr. Ramin Shafieian R. Dadrast

What is SARS? A severe acute respiratory illness that has recently been reported in some countries. A new mutation of Coronavirus is suspected as the cause. Majority of patients are adults.

Coronavirae Family

Coronavirus family also has the property of surviving in dry air/surfaces for up to 3 hours. In these conditions, the virus crystallizes, and can float in the air like dust. It is suspected that the SARS virus can be transmitted in this manner. Schematic view of a crystallized virus particle

How does SARS spread? NOT likely airborne (recent concern?) Droplets - Via close contact with an infected person Contaminated working surfaces (e.g. fomites, stainless steel, doorknobs) ~ survival up to 6 hours

Methods of Transmission Most frequent method of transmission of coronavirus from person to person is droplet transmission. If the sick person coughs or sneezes, the virus can be carried in saliva droplets to people nearby, infecting them.

Incubation period is typically 2-7 days, may be up to 10 days.

Symptoms and Signs of SARS Fever Chills Headache General feeling of discomfort Body aches Dry non-productive cough Breathing difficulty Hypoxia

Symptoms of SARS Symptoms Fever Chills Malaise Headache Myalgias Cough Dizziness Rigors Sore throat Runny nose Productive cough Frequency 100% 92% 90% 48% 67% 50% 49% 44% 43% 39% 36%

Clinical Course of SARS Most patients adults aged 25-70 years, has occurred in children. Begins with fever > 38 C, often with chills and shaking, sometimes headache, malaise, muscle aches. May initially have only mild respiratory symptoms After 3-5 days, lower respiratory phase begins with dry cough. 80 90 % begin to recover slowly by day 6 or 7. 10 20 % have severe respiratory illness which might require mechanical ventilation (ARDS). Case fatality rate 3.5%

Suspect case : 1. A person presenting after 1 November 2002 with history of : High fever (> 38 o C) And Cough or breathing difficulty And one or more of the following exposures during the 10 days period to onset of symptoms: Close contact with a person who is a suspect or probable case of SARS; History of travel, to an affected area Residing in an affected area

Suspect case: (continue) 2. A person with an unexplained acute respiratory illness resulting in death after 1 November 2002, but on whom no autopsy has been performed. And one or more of the following exposures during to 10 days prior to onset of symptoms: Close contact, with a person who is suspect or probable case of SARS; History of travel to an affected area Residing in area an affected.

Probable case: 1. A suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (RDS) on chest X-ray (CXR). 2. A suspect case with autopsy findings consistent with the pathology of RDS without an identifiable cause.

EXCLUSION criteria: A case should be excluded if an alternative diagnosis can fully explain the illness.

1) Close Contact : having cared for, lived with, or had direct contact with respiratory secretions or body fluids of a suspect or probable case of SARS. 2) Affected area : an area in which local chain(s) of transmission of SARS is/are occurring as reported by the national public health authorities.

Diagnostic Testing : Initial diagnostic Testing should include: CBC - Platelets Creatinine Phosphokinase Levels Transaminases Levels Plasma Sodium Chest Radiograph Pulse Oximetry Blood Cultures Sputum Gram s Stains and Cultures Testing for Viral Respiratory Pathogens

Chest X-ray : Chest radiograph might be normal during the febrile prodrome and throughout the course of the illness. In a substantial proportion of the patients the respiratory phase is characterized by early focal interstitial infiltrates progressing to more generalized, patchy and interstitial infiltrates. Some chest radiographs from patients in late stages of SARS also have shown areas of consolidation.

Treatment : Because the etiology of SARS has not been determined definitely, treatment is empirical and includes: Variety of antibiotics to presumptively treat known bacterial agents of atypical pneumonia. Antiviral agents such as Oseltamivir or Ribavirin. Steroids have also been suggested.

Convalescent cases of SARS: We advise that the following criteria are considered prior to making a decision regarding a convalescent case: Clinical symptoms/findings: Afebrile for 48 hours Resolving Cough Laboratory Tests (If previously abnormal): White cell count returning to normal Platelet count returning to normal Creatine Phosphokinase returning to normal Plasma Sodium returning to normal C Reactive Protein returning to normal Radiological Findings: Improving Chest X-ray changes

SARS is less infective than Influenza. Each year more than 35000 people die in the United States alone from influenza and 114000 need to be admitted in hospitals.

Prevention v Infection control precautions should be continued for SARS patients for 10 days after respiratory symptoms and fever are gone. v During this 10 days period all members of household with SARS patients should carefully follow recommendations for hand hygiene. v Each patient with SARS should cover his/her mouth and nose with a tissue before sneezing or coughing.

Prevention (continue) v Disposable gloves should be considered for any contact with body fluids from a SARS patient. v SARS patients should avoid sharing eating utensils, towels and bedding with other members of the household. v Common household cleaners are sufficient for disinfection. v Other members of household need not restrict their outside activities unless they develop symptoms of SARS, such as a fever or respiratory illness.

Clinicians evaluating suspected cases should use standard precautions together with airborne and contact precautions.

Precautions To Take When Visiting ICUs Leave all personal belongings, not relevant to the visit, in the office. Take a N95 or FFP-1grade mask from the office. Before entering the unit, put on the mask as per instructions, and check for leakage. After entering the unit, ask for a pair of surgical gloves before handling equipment. Do not place belongings, tools etc on the floor or on exposed surfaces. Request a paper towel from the staff to spread on the surface. If you need to bring equipment/parts back to the office, have them sterilized according to hospital procedure by a member of the ICU staff.

When Leaving The ICU After exiting the unit, remove the mask first and discard it, then remove the gloves. Wash hands thoroughly with chlorhexidine scrub solution. Do not re-use a mask. Do not touch a used mask without wearing gloves.

Prevention of Respiratory Tract Infection DON Ts 1. Cough or sneeze into your hands 2. Share food, cups, straws, cigarettes, hand towels 3. Chew Pens, pencils, etc. 4. Put your chopsticks, forks, spoons into communal dishes 5. Visit friends if you or they have flu-like like symptoms

Who is at the most risk of the contracting SARS? Primarily those people who have had direct close contact with an infected person.

Travel restrictions At this time it is advised to postpone non-essential travel to affected areas (China, Hong Kong, Vietnam, Singapore and Canada).

Until 12 April 2003 a cumulative total of 2960 SARS cases and 119 deaths have been reported from 21 countries of all 5 continents.

How about our country?