CARIBBEAN EPIDEMIOLOGY
CENTRE
Surveillance
guidelines in response to Severe Acute Respiratory Syndrome (SARS) global
epidemic
at
national level
According to
the current knowledge on SARS global epidemic at 28 March 2003
1 - Targeted audiences
- Clinical personnel: doctors, nurses, etc. (anybody
in regular close contact with the suspected/probable SARS case).
- Hospital clinical laboratory staff and/or public
health laboratories
- Ministries of Health and Hospital Administration
2 - Overall objective
Strengthen surveillance and infection control measures
in CAREC member countries
3 - Specific objectives
- Raise awareness on SARS risks and good surveillance
practices
- Provide CMC adapted guidelines for SARS case
management and investigation
- Reduce the risk of transmission of SARS infection
(good infection control practices)
- Ensure appropriateness of clinical sample taking,
transportation in-country and overseas shipment to reference
laboratories
4 - Messages for each of the
audiences
To this date cases of SARS
can only be imported cases in CAREC member countries.
Clinical personnel
(doctors and nurses)
·
Clinicians must be on the alert for any severe febrile acute
respiratory syndrome with a history of travel within 10 days to SARS
affected countries – refer to full case definition in the next
Guidelines section.
·
Clinicians will also play an essential role in specimen
collection and in notifying SARS suspected cases to the national health
authorities and laboratory.
National laboratory personnel
- Shall ensure the quality of the samples and the
completeness of the information collected
- Prepare
the samples for safe transportation to reference laboratories, having
given prior notification to these reference laboratories.
Ministries of
Health and Hospital Administrations
- Ensure that these guidelines are disseminated to the
relevant authorities and implemented by all health care personnel.
- Provide the appropriate
arrangements for isolation facilities and sundries to allow infection
control measures to be implemented at all required levels.
5 – Guidelines for activities
5.1 -
SURVEILLANCE
Surveillance activities
should focus on the following case-definition (revised 18 March 2003)
Suspect Case
A person presenting after 1
February 2003 with history of :
- high fever (>38oC or 100.4F)
AND
- one or more respiratory symptoms including cough,
shortness of breath, difficulty breathing
AND one or more of the following:
- close contact*, within 10 days of onset of symptoms,
with a person who has been diagnosed with SARS
- history of travel, within 10 days of onset of
symptoms, to an area in which there are reported foci of transmission of
SARS (regurlarly check WHO updates at http://www.who.int/csr/sars/en
Probable Case
A suspect case with chest
x-ray findings of pneumonia or Respiratory Distress Syndrome
OR
A suspect case with an
unexplained respiratory illness resulting in death, with an autopsy
examination demonstrating the pathology of Respiratory Distress Syndrome
without an identifiable cause.
Comments
In addition to fever and
respiratory symptoms, SARS may be associated with other symptoms
including: headache, muscular stiffness, loss of appetite, malaise,
confusion, rash, and diarrhea.
*Close contact means having cared for, having lived
with, or having had direct contact with respiratory secretions and body
fluids of a person with SARS.
- Report immediately to the national
Epidemiologist and inform National Public Health Laboratory.
- Monitor occurrence of acute febrile illness among
hospital workers and close family contacts of SARS suspected cases.
5.2 - MANAGEMENT OF
CASES AND CONTACTS
MANAGEMENT OF SUSPECT
CASES
- Patients with symptoms of SARS should be triaged
immediately to designated examination rooms or wards
- Patients with with suspected SARS should be issued
with surgical mask
- Obtain and record detailed clinical, travel and
contact history including occurrence of acute respiratory diseases in
contact persons during the last 10 days
- Take chest X-ray (CXR) and full blood count
(FBC)
if CXR is normal:
- Provide advice on personal hygiene, avoidance of
crowded areas and public transportation, remain at home until well
- Discharge with advice to seek medical care if
respiratory symptoms worsen
if CXR demonstrates uni- or
bi-lateral infiltrates with or without interstitial infiltration
- SEE MANAGEMENT OF PROBABLE CASES
MANAGEMENT OF PROBABLE
CASES
- Hospitalize under isolation or cohorted with other
SARS cases
- Send samples for laboratory investigation (if
possible) and exclusion of known causes of atypical pneumonia – for
sample collection procedures, refer to the attached document to CAREC
Alert # 2:
o nasopharyngeal
swabs/aspirates
o blood for serology
o post mortem examination as
appropriate
This
should be co-ordinated through your national public health authority and
CAREC. Samples should be investigated in laboratories with proper
containment facilities (BSL3).
- Immediately REFER samples
to the national Public Health Laboratory at room temperature. IF
this will take more than 4 hours, samples should be refrigerated (+ 4C)
and transported with ice-packs.
- CXR as clinically indicated
- treat as clinically indicated
Comments:
Before giving any treatment collect appropriate samples
e.g. nasopharyngeal swabs or aspirates and blood without anti coagulants
(red top tubes)
Fill in the appropriate laboratory forms with date of
onset of the illness and date of sample collection and print clearly
SARS suspected case on the
form. Send samples to the National Public Health Laboratory at room
temperature following universal transportation procedures. If this
takes more than 4 hours, samples should be refrigerated (+4C) and
transported with ice-packs.
Broad-spectrum antibiotics have
not appeared to be proven effective in halting SARS progression to date.
Intravenous ribavirin and steroids may have stabilised the condition of
one critically ill patient.
MANAGEMENT OF CONTACTS
OF SUSPECTED AND PROBABLE CASES
- Provide reassurance
- Record name and contact details
- Provide advice in the event of fever or respiratory
symptoms to:
o immediately report to
doctor/physician/health authority
o not report to work until
advised by health authority
o avoid public places until
advised by health authority
o minimize contact with
family members and friends
- Implement the following Hospital Infection Control
Measures
CARE FOR PATIENTS WITH
PROBABLE SARS: HOSPITAL INFECTION CONTROL MEASURES
WHO advises strict adherence with the barrier
nursing of patients with SARS using precautions for airborne, droplet and
contact transmission.
Triage nurses should rapidly
divert persons presenting to their health care facility with flu-like
symptoms to a separate assessment area to minimise transmission to others
in the waiting room. Suspect cases should wear surgical masks until SARS
is excluded.
Patients with probable SARS should
be isolated and accommodated as follows in descending order of
preference:
- Negative pressure rooms with the door closed
- Single rooms with their own bathroom
facilities
- Cohort placement in an area with an independent air
supply and exhaust system.
- If an independent air supply is unfeasible, turning
off air conditioning and opening windows for good ventilation is
recommended
Wherever possible, patients under investigation
for SARS should be separated from those diagnosed with the
syndrome.
Disposable equipment should be
used wherever possible in the treatment and care of patients with SARS. If
devices are to be reused, they should be sterilised in accordance with
manufacturers' instructions. Surfaces should be cleaned with broad
spectrum (bactericidal, fungicidal, and virucidal) disinfectants of proven
efficacy.
Patient movement should be avoided
as much as possible. Patients being moved should wear a surgical mask to
minimise dispersal of droplets. NIOSH standard masks (N95), often used to
protect against other highly transmissible respiratory infections such as
tuberculosis, are preferred if tolerated by the patient. All visitors,
staff, students and volunteers should wear a N95 mask on entering the room
of a patient with confirmed or suspected SARS. Surgical masks are a less
effective alternative to N95 masks.
Handwashing is the most important hygiene measure
in preventing the spread of infection. Gloves are not a substitute
for handwashing. Hands should be washed before and after significant
contact with any patient, after activities likely to cause contamination
and after removing gloves. Alcohol-based skin disinfectants formulated for
use without water may be used in certain limited circumstances.
Health care workers are advised to
wear gloves for all patient handling. Gloves should be changed between
patients and after any contact with items likely to be contaminated with
respiratory secretions (masks, oxygen tubing, nasal prongs, tissues).
Gowns (waterproof aprons) and head covers should be worn during procedures
and patient activities that are likely to generate splashes or sprays of
respiratory secretions.
HCWs must wear protective eyewear
or face-shields during procedures where there is potential for splashing,
splattering or spraying of blood or other body substances.
HCWs are advised to wear masks. Particulate
filter personal respiratory protection devices capable of filtering 0.3um
particles (N95) should be worn at all times when attending patients with
suspected or confirmed SARS.
Standard precautions should be applied when
handling any clinical wastes. All waste should be handled with care to
avoid injuries from concealed sharps (which may not have been placed in
sharps containers). Gloves and protective clothing should be worn when
handling clinical waste bags and containers. Where possible, manual
handling of waste should be avoided. Clinical waste must be placed in
appropriate leak-resistant biohazard bags or containers labelled and
disposed of safely.
Comments
Please note that this situation
is rapidly evolving and that the advice given will be constantly changing
as more evidence about the causation and options for treatment becomes
available.
5.3 - GUIDELINES FOR
NATIONAL LABORATORY PERSONNEL
- Check that date of onset of
the illness and the date of sample collection are correctly recorded on
the laboratory forms.
- Check samples for
appropriateness.
Reminder -- samples
for laboratory investigation and exclusion of known causes of atypical
pneumonia should be:
o nasopharyngeal
swabs/aspirates
o blood for
serology
o post mortem examination
as appropriate
This
should be co-ordinated through your national public health authority and
CAREC.
Make relevant arrangement for
dry ice availability
- From
now on, refer to Laboratory Safety Guidelines below
- Separate serum from clot and
collect serum in sterile leak-proof vials.
- Prepare
samples for preservation and overseas shipment to reference laboratory
(CAREC or otherwise) in dry ice.
- All the above steps must happen as quickly as
possible so the shipment takes place as soon as possible.
- Fill-in the appropriate
laboratory reference forms, PRINT “SARS suspected
cases” clearly on all forms.
LABORATORY SAFETY
GUIDELINES FOR HANDLING SUSPECTED SARS SAMPLES
Specimen may be
processed for packaging and distribution to reference laboratories for
further testing in a containment Level 2 laboratory.
When handling the
SARS specimens the following should be implemented:
·
The use of respirators which filter >90% of particles
ranging from 0.5 um to 1.0 um e.g. N95 respirators from 3M.
·
Safety glasses or eye shields as necessary
·
Laboratory coats
·
Gloves
·
Manipulations that may produced aerosols should be carried
out in a certified biological safety cabinet (BSC)
·
Centrifugation of blood should be carried out using sealed
centrifuge cups and unloaded in a BSC
·
Any activities that bring hands into contact with mucosal
surfaces such as eating, drinking, smoking and applying make-up are
prohibited in the laboratory.
·
Protective clothing must not be worn outside the work area
and must be placed in separate containers or laundry bags and autoclaved
before being washed or discarded. Under no circumstances must protective
clothing be taken home to be laundered.
·
Proper hand washing is required before leaving the
laboratory.
Decontamination
·
Commercially available household bleach solution containing
5.25% hypochlorite, when diluted 1:10 is effective in routine
decontamination of surfaces and instruments after working with SARS
possibly infected materials.
·
Contaminated items such as pipettes, disposable loops etc.
should be immersed in decontamination solution until autoclaving.
·
Spills involving samples should be flooded with
decontamination solution and soaked for 20-30 minutes before clean up
·
Persons involved in the clean up of spills should wear
gloves, safety glasses, and a laboratory coat or gown during the clean up
process.
·
Respiratory protection should be considered for spills in
which a substantial aerosolization is suspected when handling the
samples.
Waste Disposal:
·
All infectious waste must be placed in autoclavable pans or
bags for decontamination.
·
Disinfectant solution must be placed in discard pans so as
to begin the decontamination process.
·
All infectious waste must be autoclaved and / or incinerated
before disposal
·
Waste should be autoclaved as close to the point of
generation as possible.
·
Biological indicators must be used to monitor the
effectiveness of the autoclaving process. Waste may also be autoclaved
centrally (away from the lab) however, it must be packaged in leakproof
bags and containers and must be properly transported to the central
autoclave.
·
After autoclaving, ideally, all waste should be incinerated
for complete destruction.
·
All waste handlers must be properly trained to handle
infectious laboratory waste.
Transportation of
specimens
Specimens should be
sent as “diagnostic specimens” in accordance with the International Air
Transport Association dangerous goods regulations http://www.iata.org/dangerousgoods/index and http://www.hazmat.dot.gov/rules.htm.
For complete
packaging instructions see http://www.cdc.gov/ncidod/sars/pdf/packingspecimens-sars.pdf
WARNING ON
ADDRESSING:
Before sending
samples, please contact CAREC Customer Service:
Fax: (1.868)
628-9302
Ph: (1.868)
622-4261/2
Samples have to be sent
to
The Director of CAREC
16-18 Jamaica
Boulevard
Federation Park
PORT of SPAIN
Trinidad
West Indies
References:
- PPHSN Interim Guidance:
March 19 2003, Management of SARS
- CDC Interim domestis
infection control guidance in the Health care and community setting for
patients with suspected SARS
- WHO Communicable Disease
Surveillance and Response, SARS updates and guidelines
