HA Guidelines on Severe Acute Respiratory Syndrome

Case Definition	Admission Criteria	Diagnostic Tests	Treatment	Infection Control in Inpatient Setting
Infection Control at Home	Convalescence	Post-Mortem Examination	Appendix	Print Full Version

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A. Case definition (3/4/2003) Print this section

Box 1 Criteria for reporting to HA SARS Registry: (03/04/2003)

1. Presence of new radiological infiltrates (CXR or #CT) compatible with pneumonia, and

2. Fever 38¢XC, or history of such any time in the last 2 days, and

3. At least 2 of the following:

a. Chills any time in the last 2 days

b. New or increased cough

c. General malaise

d. Typical physical signs of consolidation

e. Known history of exposure

If no known history of exposure, consider exclusion if presence of any one of the following:

1. XR show lobar consolidation

2. The pathogen is already known

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B. admission criteria (3/4/2003) Print this section

Chart 1 ¡V AED Flowchart for patients with definite contact with Severe Acute Respiratory Syndrome patients (within 10 days) (please click to view chart).

Chart 2 - AED Flowchart for patients with no definite contact with Severe Acute Respiratory Syndrome patients (please click to view chart).

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c. Diagnostic Tests (3/4/2003) Print this section

1. The Rapid diagnostic test (RT-PCR) is still in the developmental phase. It should not be used to exclude SARS and it is not useful as a screening test.

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D. Treatment (3/4/2003) Print this section

1. The most efficacious treatment regimen at present is unknown but better experience definitely considered in this guideline.

2. An empirical approach yielding encouraging results consists of an initial potent antibiotic cover for presumptively known bacterial agents of severe pneumonia, followed by simultaneous use of iv high dose methyiprednisolone and iv ribavirin. As the disease progresses or when there is clinical deterioration, respiratory support from high concentration oxygen to assisted ventilation might be needed.

For Adult Patient

3. Community acquired pneumonia characteristic of SARS, esp. from known exposure of outbreak source and/or poor condition on presentation

Broad-spectrum potent antibiotics + Methylprednisolone + Ribavirin

4. Community acquired pneumonia not fulfilling SARS definition and/or patient in good general condition on presentation

Broad-spectrum antibiotic + Close observation

5. If general condition deteriorates with signs and symptoms of SARS (esp. increase fever, lethargy, lymphopenia & thrombocytopenia)

Treat as in 3)

* Broad-spectrum antibiotics

6. Majority of the cases cannot afford to lose time, start with broad-spectrum potent antibiotics:

Either

IV Rocephin 1g Q24H, or Tazocin 4.5g Q8H, or Maxipime 2g

Q8H plus Clarithromycin 500mg BD PO

Or

Replace with Levofloxacin 500mg daily plus Clarithromycin if

allergic to penicillin)

7. Milder & less aggressive form can be treated with Augmentin plus Clarithromycin/Azithromycin

* Steroid + Ribavirin

8. The most potent regime is to use the 2 together especially if:

¡P Extensive/bilateral CXR involvement, OR

¡P Persistent CXR involvement AND persistent high fever for 2 days, OR

¡P Clinical/CXR/Lab parameters suggestive of deterioration (persistent/increasing lethargy is an important sign), OR

¡P CXR abnormality AND SpO2<95% on Room Air

9. For Steroid, the consensuses are:

¡P Use at the same time with ribavirin to avoid cytokine storm and immune activation.

¡P High dose IV

¡P Methylprednisolone (MP) is better than Hydrocortisone

¡P Pulse MP may improve clinical course if use early

10. For Ribavirin, the consensuses are:

¡P IV route is preferred in severe cases

¡P IV 400mg Q8H for 10 to 14 days

11. Typical regimen of steroid treatment

¡P IV MP 3mg/kg/day x 5 days, then

2mg/kg/day x 5 days, then

1mg/kg/day x 5 days, then

Oral Prednisolone to tail off rapidly in 6 days

12. In case of deterioration (at least 2 of clinical/CXR/ SpO2 and persistent lymphopenia)

¡P Increase to pulse MP 500mg bd x 2 days then back to 3mg/kg/day, total treatment period maintained for 21 days.

¡P Monitor blood sugar and signs of sepsis while on pulse MP.

13. Use of BIPAP/CPAP

BIPAP and CPAP may reduce the need for assisted ventilation if given early (e.g. first sign of lethargy). However, since there is a significant risk of spreading the infection, these procedures should not be used for all patients. If deemed medically really necessary, they should be performed under airborne precautions such as negative pressure isolation rooms (with 6-12 air changes/hour) and use of protective hoods (powered air purifying respirator system).

For Paediatric patients

14. History of contacts, progressive radiological infiltrates and lymphopenia are important in making the diagnosis.

15. 3^rd generation cephalosporin (e.g. Cefotaxime) plus macrolide (e.g. Erythromycin or Clarithromycin) for coverage of usual pathogens of CAP

16. Commence Ribavirin 40-60 mg/kg/day po div Q8H if contact history definite and with fever (oral bioavailability of ribavirin is 20-64%. It may not be effective if virus load is high).

17. In highly suspected case or rapidly progressive disease, start steroid at the same time with ribavirin. Methylprednisolone 3 mg/kg/day/IV or Hydrocortisone 1-2 mg/kg iv Q6h or Prednisolone 1-2 mg/kg/day po div BD depending on severity and urgency.

18. If fever persists, or clinical deterioration or progressive CXR changes, pulse Methylprednisolone 10 mg/kg/dose iv Q24H for up to 3 doses, depending on clinical response plus Ribavirin 20-60 mg/kg/day iv div Q8H (maximum dose used in some adult patients is 60 mg/kg/day or 1.2 g Q8H).

19. Continue with prednisolone 1-2 mg/kg/day or Hydrocortisone 1-2 mg/kg iv Q6H after pulse methylprednisolone. If condition improves at 1-2 weeks after commencement of steroid therapy, start tapering of steroid over 1 week. If CXR returns to normal by 2-3 weeks, may stop steroid or rapid tail off over a few days. If CXR is still abnormal by 3 weeks, try slow tapering of the steroid according to clinical and radiological improvement.

20. Ribavirin will be given for a total of 10-14 days. Antibiotics may be discontinued if afebrile for 5 days. However patients started on pulse steroid should be carefully observed for secondary infection.

21. The antibiotic regimen can be modified on clinical grounds if secondary or hospital acquired infection is suspected after prolonged stay in ICU and course of high dose steroid.

Special precautions

Ventilator

22. BiPAP, CPAP, and nebulizer or nebulized medication should not be used for all patients.

23. If intubation and assisted mechanical ventilation is required, a closed suction system should be incorporated into the ventilator circuit and scavenging should be provided by the vacuum wall suction.

Steroid

24. Methylprednisolone must not be administered via central venous catheters to avoid precipitating cardiac arrest or arrhythmia.

25. Hypokalaemia, hyperglycaemia and hypertension are commonly seen after administration of high dose steroid. Concomitant anti-ulcer prophylaxis should also be given.

Ribavirin

26. Ribavirin may be accumulated in patients with impaired renal function but not in patients with decompensated liver disease.

27. Adverse events associated with the use of Ribavirin:

Haematological	haemolytic anaemia, reticulocytosis
Cardiovascular	cardiac arrest, hypotension, bradycardia, tachycardia
Neurological	dizziness, asthenia, seizure
Renal	nephrolithiasis
Hepatic	elevated serum bilirubin and ammonia
Metabolic	increase in uric acid
Dermatological	pruritus, rash, skin eruptions

Pregnancy and SARS

28. Admit all pregnant SARS patients to designated medical wards.

29. If it is less than 13 weeks of gestation and the mother has been prescribed ribavirin, termination of pregnancy (TOP) should be advised after she has recovered from the disease.

30. If medically indicated, caesarean section should be conducted in a room with negative pressure ventilation.

31. All patients on ribavirin should be advised to practice contraception for 6 months.

(Please click for the detailed guidance)

Treatment using convalescent patient serum

32. Convalescent patient plasma (CPP) infusion is an exploratory treatment modality proposed for desperate cases following anecdotal reports of response in PWH. Clinician must carefully balance the risks to both the donors and the recipients. The feasibility and logistics of procuring CPP are under active review.

Prophylactic Treatment

33. Not all contacts will contract the virus or develop a severe form of the disease. The benefit of improving an individual person¡¦s health or public health is unknown. The duration of protection is primarily limited by the duration of treatment. In view of the serious side effects of Ribavirin and possible development of drug resistance, prophylactic use is normally not recommended and widespread use of the drug may cause more harm than benefit.

Pre-emptive treatment

34. Whether early intervention with antiviral drug and steroid can improve clinical outcome remains an attractive but unproven option. The difficulty lies in the lack of reliable rapid diagnostic test for SARS. Suspected SARS patients, not fulfilling all diagnostic criteria but with close contacts with proven SARS, should be closely observed and not empirically treated with Ribavirin.

Suspected SARS cases by primary care physician in outpatient setting

35. All patient should have a CXR reported by a radiologist.

36. Start standard therapy including a beta-lactam (penicillin & cephalosporin groups) and coverage for atypical pneumonia (a fluoroquinolone, tetracyclines, or a macrolide) for 2 days.

37. Advise patient to return if symptom deteriorates or new symptom develops.

38. Follow up all patients at day 3. Continue treatment if condition improve / stable or refer to AED if:

Fever > 38¢XC and Respiratory symptoms - either shortness of breath or cough and X-ray shows pulmonary infiltrate and (either no response to above-mentioned treatment or patient having been exposed with pneumonia in the previous 2 weeks.)

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E. Infection Control in Inpatient setting (5/4/2003) Print this section

Box 2 Essential Infection Control Advice

1. Be vigilant at all times.

2. All staff MUST receive infection control precaution training.

3. All persons inside hospital settings MUST wear a mask. For N95 mask, ensure right size and check for leakage.

4. All persons inside hospital settings MUST practise hand hygiene. Avoid touching mask and/or face. Wash hands after touching mask, patients or any suspicious surfaces.

5. Minimise traffic of personal belongings into and out of clinical areas as far as possible.

High index of suspicion

1. Practice infection control precautions in all healthcare settings.

2. AED, admission wards, medical wards, paediatrics wards, operation theatres, labour wards and XR departments should be treated as high-risk areas.

Note: initial presentation of SARS may be non-specific and only become more apparent after admission.

Training and Enforcement

3. All personnel working inside an inpatient setting (regardless of SARS risk) must receive training/instructions on infection control precautions against SARS. This applies to our employees as well as contractor staff. All hospitals MUST set up an infection control enforcement team to monitor compliance and identify areas of improvement.

Environmental Control

4. Cohort patients: separate "probable / confirmed SARS" from "suspected SARS" from "other patients without suspicion of SARS".

Note: Patients with unexplained fever should be cohorted whenever possible

5. Disinfect all clinical areas (at least once daily or more frequent if indicated) and facilities, equipment (regularly and after used) with household bleach 1 in 49 dilution (non-matalic items) and 70% alcohol (matalic items). Facilities contaminated with vomitus, body secretions and excreta must be cleaned and disinfected immediately. (Click here for Chinese version of Guidance Notes on Disinfection and Cleansing of Environment and Equipment.)

6. Prevent cross-contamination of Equipment. SARS cohorting ward and ICU: Avoid crossing over of equipment and other items between wards. If possible, assign them (e.g. bed pan, scissors, thermometers, stethoscope, sphygmomanometer) for designated patient use. If sharing is unavoidable, items must be cleaned and disinfected before using on other patients, e.g. by 1 in 49 dilution household bleach (hypochlorite).

Control Access by Visitors

7. Do not allow visit unless under very exceptional situations. In such circumstances, visit must be kept to minimal (preferably no longer than 15 minutes) and documented. Educate all visitors to take full barrier precautions (surgical mask, gown, gloves, protective eyewear) and their responsibility for adherence to them. Visitors should wash their hands when leaving the area.

Personal Practice

All hospital settings

8. All persons MUST wear a mask (Click here for Correct Use of Mask and click here for¡uÄY«©I§l¨t²Îºî¦X¯gÂåÅ@¤Hû·P¬V±±¨î±¹¬I¹Ï¸Ñ«ü¤Þ¡v).

9. All persons MUST practice hand hygiene (frequent hand washing, avoid touching the eyes, nose and mouth). (Click here for a Chinese version of the Guidance Notes on Hand Washing).

All inpatient settings

10. Standard precautions: Hand hygiene (wash hand after handling individual patients and removing gloves and gowns). Avoid touching the eyes, nose and mouth. Do not eat or drink in inpatient areas or pantry adjacent to inpatient areas.

Note: Both antiseptic use (e.g. hibiscrub) and the physical action of washing with water are crucial for effective hand hygiene. Hexol-rub or alcohol wipe CANNOT replace hand washing.

11. Droplet precautions: Surgical masks for all patient contact. Protective eyewear (goggles or face shield) for close patient contact.

12. Contact precautions: Wash hand before nursing another patient. Protective gowns and gloves for contact with the patient or their environment (must wear gowns in procedures likely to generate splashes or sprays of blood and body fluids).

SARS cohorting ward or ICU

13. Put on a surgical / N95 mask. (Click here for Correct Use of Mask and click here for¡uÄY«©I§l¨t²Îºî¦X¯gÂåÅ@¤Hû·P¬V±±¨î±¹¬I¹Ï¸Ñ«ü¤Þ¡v.

Note: N95 masks are available to staff on request. However, its perceived benefit must be balanced against user compliance to correct usage.

14. More stringent contact precautions: use of cap, gown, gloves and protective eyewear; carry as few personal belongings as possible during work and avoid bringing items into and out of clinical areas as far as possible, e.g. patient records, pagers, stethoscopes and other personal gears including pens and notebooks, etc.

15. Precautions on entering and leaving SARS cohorting areas

On ENTERING (In sequential order)

i. Put on a mask

ii. Put on protective eyewear (especially if there is close patient contact)

iii. Put on a cap

iv. Put on a gown

v. Rub hands with alcoholic handrub and allow to dry

vi. Put on gloves

vii. Enter the ward / ICU

On LEAVING (in sequential order)

i. Remove gloves (dispose into waste bag)

ii. Remove cap (dispose into waste bag)

iii. Remove protective eyewear, clean with 70% alcohol and store in labeled paper bag

iv. Remove gown (dispose into waste bag)

v. Remove mask; discard if contaminated, or store in labeled paper bag for reuse.

vi. Rub hands with alcoholic hand rub and allow to dry (if hands soiled, must wash hands before leaving the ward)

vii. Put on a surgical mask whilst outside high-risk area.

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16. Continue infection control precautions at home. Consult staff clinic or AED if fever or respiratory symptom develops.

Waste Management of Disposable Protective Equipment

17. Disposable masks, caps, gloves, gowns and shoe covers exposed to SARS patients should be handled as clinical waste, i.e., discard into Red Bags, properly packaged and labelled for delivery to incineration.

Additional Precautions in High-risk Procedures

Serious-risk procedures:

18. The initial presentation of SARS could be non-specific. A number of breakthrough infections was caused by patients who were initially admitted for non-specific presentation but were subsequently confirmed to have SARS. Therefore, aerosolized medication treatments (by nebulizer) and BiPAP and cPAP should not be used for all patients.

19. If deemed medically essential, the above procedures should only be performed in consultation with respiratory physicians, and under high airborne precautions such as strong negative pressure isolation rooms, and use of strict protective gears by healthcare personnel.

High-risk procedures

20. Potentially aerosol-generating procedures (diagnostic sputum induction, bronchoscopy, airway suctioning, endotracheal intubation), laboratory handling and processing of fresh specimens associated with SARS, post-mortem examination of human remains of SARS patients.

i Performed only if deemed medically necessary.

ii Limit the extent of procedure to the minimum necessary.

iii Limit the number of personnel to the minimum necessary.

Additional precautions

21. Laboratory processing of fresh SARS specimen should be performed in a biological safety cabinet. If centrifugation is required, it should be carried out using sealed centrifuge cups or rotors that are loaded and unloaded in a biological safety cabinet.

22. Contact precautions should vary with the risk of exposure. For post-mortem examination, for example, protective garments should include surgical scrub suit, surgical cap, impervious gown or apron with full sleeve coverage, eye protection (goggles or face shield), shoe covers and double surgical gloves with an interposed layer of cut-proof synthetic mesh gloves. Make sure that the protective outer garments are removed when leaving the immediate autopsy area and discarded in appropriate laundry or waste receptacles.

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F. Infection Control measures at home (3/4/2003) Print this section

1. All staff caring for SARS patients / contacts of SARS patients or SARS patients discharged from hospital should adopt the following infection control measures at home:

i. Frequent handwashing with liquid soap rather than bar soap, especially after contact with nose, mouth and respiratory secretions, e.g. after sneezing.

ii. Family members should practise handwashing frequently, and avoid touching the eyes, nose and mouth with their hands.

iii. Put on a surgical mask.

iv. Avoid close contact with family members (e.g. mucosal contact).

v. Avoid sharing food and utensils with family members.

vi. Shower immediately after work (for staff caring for patients with Severe Respiratory Syndrome).

vii. Cleanse and disinfect the facilities (including furniture and toilet facilities) regularly (at least once a day), using diluted household bleach (i.e. adding 1 part of household bleach to 99 parts of water), rinse with water and then mop dry.

viii. If the facilities are contaminated with vomitus or body secretions, wash / wipe with diluted domestic bleach (mixing 1 part of bleach with 49 parts of water) immediately.

ix. These precautionary measures should be adopted for 10 days from the latest contact with patient with Severe Respiratory Syndrome, and for 3 weeks for discharged patients with Severe Respiratory Syndrome.

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G. CONVALESCENCE (3/4/2003) Print this section

1. The potential for continued viral shedding during convalescence is under investigation. A cautious approach is to cohort convalescence cases in [hospital / convalescence facilities / home] for up to 3 weeks from onset of illness, or at least 7 days since convalescence, whichever is longer.

2. Definition of Convalescent Cases

Clinical symptoms/findings:

Afebrile for 48 hours

Resolving cough

AND Laboratory tests: if previously abnormal are improving

White cell count returning to normal

Platelet count returning to normal

Creatine phosphokinase / LDH returning to normal

Liver function tests returning to normal

Plasma sodium returning to normal

C reactive protein returning to normal

AND Radiological findings:

Improving chest x-ray changes

Home care

3. Upon discharge, advise patients to self-quarantine and take enteric precaution at home for 10 days (may be longer, studies not available). During which they should:

¡P Stay indoors and keep contact with others to a minimum.

¡P Wear mask and practice other personal hygiene measures, e.g. avoid mucosal contact, frequent hand washing, do not share eating utensils.

¡P Check temperature twice daily and report to AED (of the hospital from which they were discharged) if temperature ³38¢XC on 2 consecutive occasions.

¡P Report to AED if condition deteriorates and any further symptoms develop.

4. Follow up weekly until the chest x-ray and patient¡¦s health return to normal.

¡P At each follow up, repeat chest x-ray and full blood count (and other blood tests that were previously abnormal).

¡P Further confinement and longer follow up could be recommended for those who are immunosuppressed.

¡P Obtain convalescent serology at 7 and 14 days after the acute sample taken on or soon after the date of disease onset.

5. SARS patients on discharge must be advised to strictly follow INFECTION CONTROL MEASURES AT HOME (click here for a copy for a copy of¡u«D¨å«¬ªÍª¢¡v¯f¤H¥X°|¶·ª¾ for dissemination). 

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H. post mortem examination (5/4/2003) Print this section

Case Definition

1. Please see latest definition in use in HA..

Precautions for Mortuary Personnel

2. Indications for autopsy

i. SARS cases confirmed by PCR or serology of the newly identified Coronavirus: Unless otherwise indicated, an autopsy is not necessary. A waiver should be recommended to the Coroner for Coroner's autopsy cases.

ii. Clinically suspected or probable but unconfirmed SARS case: To minimize dissemination of virus, limit procedure to taking post mortem lung biopsies for culture, molecular and histology studies.

3. Limit the number of personnel to the minimum necessary, viz., 1 pathologist plus 1 mortuary technician/attendant if practical.

4. Handle body as per category 2 of guidelines on Precautions for handling and disposal of dead bodies, issued jointly by DH, HA and Food & Environmental Hygiene Department in January 2002 (4^th edition). (Click here to retrieve the guidelines). The deceased must be put in double plastic bag in the ward with the yellow tag tied prominently on the outside of bag to alert the ward and mortuary staff to take due precautions.

5. Protective garments: Surgical scrub suit, surgical cap, impervious gown or apron with full sleeve coverage, eye protection (e.g., goggles or face shield), shoe covers and double surgical gloves with an interposed layer of cut-proof synthetic mesh gloves.

Note: Protective outer garments should be removed when leaving the immediate autopsy area and discarded in appropriate laundry or waste receptacles.

6. Respiratory protection: N-95 mask or powered air-purifying respirators (PAPR) equipped with a high efficiency particulate air (HEPA) filter. PAPR is recommended for any procedures that result in mechanical generation of aerosols, e.g., use of oscillating saws. Autopsy personnel who cannot wear N-95 respirators because of facial hair or other fit-limitations should wear PAPR.

7. Avoid splashing and aerosols as far as possible. Perform minimal dissection of organs in the fresh state.

8. After sampling for fresh tissue, the remaining tissue should be adequately fixed in formalin at least overnight before cutting for tissue processing.

9. Despatch of specimen

Recommendation to persons collecting body

10. The mortuary officer or duty attendant should inform such persons of precautions recommended for handling dead bodies with infectious diseases listed under category 2. (please click here for details stated in Section D2 of the guidelines on Precautions of handling and disposal of dead bodies). It is advisable to provide those persons with printed copies of the Chinese version (please click here).

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Appendix: Correct use of N95 masks Print this section

The mask provides an effective barrier to prevent healthcare workers from inhaling airborne pathogens such as Mycobacterium tuberculosis. The level of protection is determined by the efficiency of the filter material and how well the facepiece fits or seals to the health care worker's face. N95 mask should not be worn when conditions prevent a good face seal, e.g. a growth of beard, sideburns, etc.

Fit check: Perform fit check before each use. Put on the mask and press the metal strip to fit contour of face. Place both hands gently over the mask and exhale vigorously to check for air leakage around the nosepiece or edge. Reposition and recheck as needed.

Reuse: N95 masks may be reused. Since it cannot be disinfected, use must be restricted to a single person. Discard if it is physically damaged or soiled.

Handling and storage: The external surface may be contaminated. Do not touch with fingers. Label (or identify by other means) your mask to avoid mixing-up. For temporary storage, use a paper bag or box but not sealable plastic bag. Sealing maintain dampness and encourages microbial growth.