Transcript SARS Experience at Prince of Wales Hospital Hong Kong

SARS Outbreak in Hong
Kong
Professor Peter Cameron
Previously
COS Prince of Wales Hospital
Chinese University of Hong Kong
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
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
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
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15 medical and 15 Nursing staff sick
5 ED docs and 3 nurses
Other pts and visitors
Medical students
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
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
Staff getting sicker
ED
Screening
Ward
Unknown
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Nature of organism
Mode of spread
Extent of spread
Outcome
Likely epidemiology
– ?world pandemic
Quarantine
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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
Reported Clinical Features
(Inpatients)
• Incubation period – 2-7 days but ?16 days
• Symptoms
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Fever 100%
Chills/rigors 73.2%
Myalgia 61%
Cough 57%
Headache 56%
Dizziness 43%
• Also N&V, diarrhea, abdo pain, coryza, sore thoat ~20%
Initial Symptoms at a Screening
Clinic
SARS - SARS+
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Fever
Chills
Malaise
Myalgia
Rigor
Cough
URI
LOA/Vomiting/Diarrhoea
37% 81%
21% 52%
20% 34%
12% 27%
4% 12%
72% 64%
neg predictor
Pos Predictors
CT Changes
Epidemiology
• Contact tracing
• Health department processes not adequate
• Expertise?
Epidemiology Amoy Gardens
Graphic of epidemiology
Infection control
• Droplet spread
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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
Airborne Spread
• Nebulisers
• Non Invasive Ventilation
• Continuum between aerosol and droplet
Engineering
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Ventilation
Toilet layout
Sewage
Negative pressure rooms
Ward layouts
Treatment
• Empiric treatment
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Antivirals - ribavirin
Steroids
Cytokine inhibitors
Convalescent serum
Traditional chinese medicine
• Ethics?
• Political pressure
Staff Morale
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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
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?
Outcomes in PWH
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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
Outcomes in HK
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~ 1700 cases
~300 deaths
Outbreak over in less than 3 months
~25% cases staff
Graph of case fatality
Community Response
• Hospitals
– Initially PWH
– Other hospitals became involved
– Infectious disease hospital
• Overloaded
Community Response
• schools
• Tourist and economy
• Goverment
Schools?
Tourists + economy?
Street sweeping
Living Life with a mask
Governments?
Wu and wen
Microbiology
• Uncertainty about organism
• Tests actually caused problems
– Not properly trialled for accuracy
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
Lessons Learnt
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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
Life Returns to normal quickly
Picture of front line
Venepuncture
Mona lisa with mask