# Presentation: 083302

## SARS:  The Challenge for VA

- Integrated Ambulatory Care Conference
*“**Bridging the Gaps”*
- June 24, 2003

***VA Office of Public Health and Environmental Hazards (13)***

## SARS

- _S_evere _A_cute _R_espiratory _S_yndrome

## SARS:  The Challenge for VA

-  Brief History
-  Transmission
-  Clinical Disease
-  Diagnosis and Laboratory Testing
-  U.S. and VA Response

## Brief History

- February 2003  Epidemic of atypical pneumonia in Hanoi, Hong Kong, Toronto, Canada and retrospectively, in Guangdong, China
- March 12 2003
- WHO issued a global alert
- CDC invoked Emergency Operations Center
- International public health response
- Contact tracing, isolation, quarantine, traveler screens
- Electronic information-sharing and communications

## Brief History

- Late March 2003  novel coronavirus identified from nasopharyngeal fluid of WHO physician and others
- Late April 2003  epidemic appeared controlled in Hanoi and Toronto, but ongoing in China and surging in Taiwan.  Most cases linked to HCF.
- May 22 2003  second wave begins in Toronto
- June 20 2003  a global epidemic
- 32 countries, 8461 cases, 804 deaths, CFR 9.5%
**under control, per WHO.  “Guarded Success”**

## SARS Transmission

- Respiratory droplet—coughing, aerosols from procedures
- Contact with contaminated surfaces—hands to eyes, nose, or mouth
- NOT
- Airborne or Food- or Water-borne
- BUT
- A stable virus—survives 1-2 days at room temperature and 4 days in organic matter
- Super-spreaders
- Individual who transmits to large numbers of others
- Host?  Viral?  Environmental?

## SARS Transmission

- McGeer, NIH SARS Conference, 5/30/03

**Pt**

**Spouse**

## SARS Transmission

- McGeer, NIH SARS Conference, 5/30/03

## Preventing SARS Transmission

- In Health Care Facility
- Hand hygiene
- Gowns and gloves
- Eye-wear (prevent hands to eyes)
- Negative flow room if available
- HCW wear N-95 filtering disposable masks

- In Community
- Hand hygiene
- Mask or cover SARS pt’s mouth and nose
- Environmental cleaning
- Transport to health care facility with “a plan”

## Clinical SARS

## Clinical Case #1

- 47 yo WHO physician epidemiologist  investigated respiratory illness outbreak in Hanoi 3/3/03-3/9/03
- Hospitalized with fever, dyspnea, myalgias 3/11/03
- Admission exam:  febrile, lungs clear, normal RR at rest
- WBC 4-6000, Plts > 200k, LDH 400
- Clear CXR

- D. Rimland, presentation to house officers 5/14/03

## Clinical Case #1

- D. Rimland, presentation to house officers Atlanta VAMC 5/14/03

- Day 3  CXR mild LLL atelectasis, small effusion
- Day 5  CXR resolution of L, new RLL atelectasis
- Day 9  Persistent fever, no response to antibiotics, CXR UL consolidation; O2 sat 87%
- Day 14  CXR diffuse bilateral interstitial infiltrates; progressive respiratory failure
- Day 19  Death from respiratory failure/cardiac arrest

## Case #1

- Points
- Short incubation period (2-10 days)
- Initial mild illness, several days before pneumonia develops
- Progressive respiratory failure  death

## Clinical Case #2

- U.S. resident traveled to Toronto 5/15, visited a sick relative in a hospital 5/16-17
- Returned to U.S. 5/18
- After 5/18, the sick relative, relative’s hospital roommate, and a visitor were diagnosed with SARS
- U.S. resident developed fever May 24, then respiratory symptoms
- Pneumonia confirmed June 3
- Negative SARS ab day 10; Positive SARS ab day 11; SARS CoV RNA undetectable by RT-PCR day 11.

- MMWR, June 13, 200/52(23);550

## Clinical Case #2

- Epidemiologic links helpful--travel to Toronto, exposure to SARS patients
- Patient aware of contact and *vigilant for symptoms*
- Health care providers had *high index of suspicion*
**Helped prevent transmission **
-  Laboratory tests
- Serology variably positive
- Nucleic acid amplication studies demonstrate sensitivities as low as 50%
- Severity of illness is variable:  US’s CFR is 0%; Canada’s is 15%

- MMWR, June 13, 200/52(23);547-550

## Diagnosing SARS

- Use the 3-part CDC case definition
- Clinical
- Fever, respiratory symptoms, pneumonia
- May be mild, moderate, or severe
- Assess patient’s ability to measure fever
- Epidemiologic
- Travel (including transit thru airport) to areas of transmission
- Contact with a known case within 10 days of onset of symptoms
- Laboratory
- Antibody to SARS Co-V during acute illness or >21 days after symptom onset
- Detection of SARS Co-V RNA by RT-PCR
- Isolation of SARS-CoV

## Classifying SARS

- _Suspect_ Case
- Moderate respiratory illness of unknown etiology
- Epidemiologic link
- Laboratory not required

- _Probable_ Case
- Severe respiratory illness of unknown etiology
- Epidemiologic link
- Laboratory not required

- Laboratory _Confirmed_ Case=  + serology; detection of SARS CoV RNA; or direct viral isolation

## SARS Laboratory Testing

- Available at state public health
- laboratories http://www.aphl.org/Infectious_Diseases/index.cfm#SARS
-  Research tests; Informed Consent needed
-  Tests available:
-  Antibody (EIA, IFA) – serum
-  RT-PCR – serum, stool, nasal secretions
-  Viral isolation by co-culture—various specimens
-  Interpretation
-  Positives—suggests SARS, false-positives possible
-  Negatives—true, false-negative, or not timed to
- antibody or viral presence
**         ***********continue isolation precautions*********

## Are we prepared?

## CDC Responds

- Comprehensive, informative web site
- Case Definition
- Tracking of cases
- Collaboration with and assistance to the international
-     community

- Recommendations for
- Isolation
- Quarantine
- Transportation
- Specimen Handling
- Laboratory Safety

## NIH Develops Research Agenda

- NIH Research Conference 5/30/03
- Clinical
- Epidemiologic
- Virologic
- Meeting summary at:
- http://www.niaid.nih.gov/sars_meeting.htm

## VA Prepares for SARS

- Informational VA web sites on SARS launched 4/3/03:
- _[http://vaww.vhaco.va.gov/phshcg/SARS/](http://vaww.vhaco.va.gov/phshcg/SARS/)__ _
- _[http://www.publichealth.va.gov/SARS/](http://www.publichealth.va.gov/SARS/)_

- _[www.publichealth.va.gov/SARS/](http://www.publichealth.va.gov/SARS/)_
- (VA Intranet - vaww.vhaco.va.gov/phshcg/SARS/)
*This site is designed to help staff and patients of the Department of Veterans Affairs to be better informed about this new disease and take actions to prevent its spread.*

## VA Prepares for SARS

- Recommends CDC guidance be followed
- Broadcasts CDC briefings on VA Knowledge Network
- Develops multi-disciplinary VA SARS Working Group
- Issues USH Directive

- _[www.publichealth.va.gov/SARS/](http://www.publichealth.va.gov/SARS/)_
- (VA Intranet - vaww.vhaco.va.gov/phshcg/SARS/)
*This site is designed to help staff and patients of the Department of Veterans Affairs to be better informed about this new disease and take actions to prevent its spread.*

## VA Prepares for SARS

**Reporting Suspect and Probable Cases of SARS **
**in VA Patients **
**1.  PURPOSE:**  This Veterans Health Administration (VHA) Directive establishes policy for the reporting of persons receiving medical care from VA facilities who have suspect and probable cases of severe acute respiratory syndrome (SARS).
**2.  Background  **
- 	a.  _**The Illness**_**.**  SARS is a new, transmissible, serious illness characterized by fever and respiratory symptoms of cough, shortness of breath, difficulty breathing, hypoxia, and radiographic findings of pneumonia.  In some patients, the illness progresses to respiratory failure requiring intensive support.  SARS has a case fatality rate of greater than 5 percent.  The etiology is thought to be a *coronavirus *(SARS-CoV).  SARS is transmitted person-to-person, by respiratory droplets or contact with environmental surfaces contaminated by droplets.  SARS has spread globally and has been suspected or has occurred in thousands of persons around the world.  SARS is treated symptomatically; there are no known effective antiviral medications to date. The United States has placed health alert notices and travel advisories to the areas of greatest SARS transmission and has added SARS to the list of quarantinable communicable diseases.  The Centers for Disease Control and Prevention (CDC) has asked that state and local health departments report _suspect_ and _probable_ cases of SARS to them.

## SARS – Issues for VA Facilities

- Education—many levels
- Employee Exposure—safety, tracking, surveillance, man-power, HR
- Engineering Controls—isolation facilities
- Laboratory—SARS and other Respiratory Pathogens
- PPE Supplies

## Summary—SARS epidemic at 100 days...

- Early detection--critical to control
- Vigilance and a high index of suspicion--necessary
- Hospitals are foci of transmission
- 90% of cases in ‘second wave’ in Toronto area are linked to contact in one hospital
- Much to learn—role of super-spreaders, laboratory testing, variability of clinical illness, treatment

## Concerns for future:

- Widespread outbreak—loss of the epidemiologic link
- Resurgence in cold/flu season

## Poster Session

- Poster describing steps in handling a suspect SARS patient in a health care facility
- Handouts
- Educational pamphlets for clinicians and patients
- Triage reminder posters
- Web site information

## VA’s SARS Web Sites

- _[http://vaww.vhaco.va.gov/phshcg/SARS/](http://vaww.vhaco.va.gov/phshcg/SARS/)_
- OR
- _[http://www.publichealth.va.gov/SARS/](http://www.publichealth.va.gov/SARS/)_

***VA Office of Public Health and Environmental Hazards (13)***