The War on SARS

National Epidemiology
Center Department of
Health
Background
Suspected to have
originated in Guandong,
China

November 2002 outbreak
of SARS in China
February 2003 reported outside China

March 12, 2003 WHO issued global
alert
March 17 Philippine DOH started response
April 11 first Philippine probable case
reported
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5212a1.htm
International spread from hotel in Hong Kong
to Viet Nam, United States, Singapore, Canada, Ireland
Epidemiological features
- health care workers and close
contacts at highest risk
- strict isolation and infection
control can halt spread
- ? super-infectors (super-
spreaders) vs. high social
mobility with many contacts
Clinical features
incubation period
exposure to SARS case
prodrome lower respiratory phase
1 to 13 days
(~2 to 5 days)
~2 days
fever (>38C)
begins ~ day 3
fever, dry cough,
short of breath
CXR changes
? very low / low low high / super-infectors
infectivity
Clinical features
continued illness
then
severe respiratory phase
~10%
~90%
intubation
mechanical ventilation
death <4%
O
2
support
slow recovery
In the first 10 patients in HK,
only one patient discharged:
off supplemental O
2
day 12;
CXR resolution day 18;
discharge day 20;
still with malaise day 26.
infectivity: unclear, possibly high to very high
patients still isolated on discharge
Infectious Agent
Cause mild to moderate respiratory illnesses such as
common cold.
Able to survive in inanimate objects for up to 4 hours; at
present, evidence points to survival of 2-4 days
Can be killed by exposure to ultra-violet light, so they
will not survive under sunlight.
Mutate easily, and each mutation triggers off an
epidemic of respiratory disease.

The name coronavirus refers
to the protein molecules
surrounding the virus, making
it look like a crown (n.corona
lat = crown).
The virus has a pattern of
proteins on its surface and
this pattern must click with
its hosts, just like the pieces
of a jigsaw puzzle. Only
when the pieces fit together
can the virus invade the cell.
Once inside the body, the
virus attaches to the cell wall
and injects itself into the
cell.
Its genetic material is
released into the human cell,
and it replicates.
The host cell bursts and
infection spreads. The fast-
mutating flu virus can
quickly become resistant to
drugs, making it difficult to
treat.
Infectious Agent
a new and previously unrecognized coronavirus that
has been detected in patients with SARS

According to the WHO,
as of May 16, 2003,
the total number of cases
of SARS worldwide is over 7000
with about 600 deaths.
(Death Rate = 7.8%)

At present, there are have been twelve cases of
SARS reported in the Philippines; two of these had
died; seven cases had been infected from one index
case (AC). Four have already recovered.

Since May 7, 2003,
the WHO has included the Philippines in the list of
areas with recent local transmission of SARS
(i.e. with more than one generation of local probable
SARS cases).


China - 5013
Hong Kong 1683/Macao - 1
Taiwan 184
Thailand - 7
Vietnam - 63
Singapore - 205
TOTAL = 7193
SARS Cases: Western Pacific and South Asia
Malaysia - 7
Indonesia - 2
Australia - 6
Philippines - 10
South Korea 2
Mongolia - 9
New Zealand - 1
India - 1
China - 252
Hong Kong 218/Macao - 0
Taiwan 20
Thailand - 2
Vietnam - 5
Singapore - 28
TOTAL = 529
Malaysia - 2
Indonesia - 0
Australia - 0
Philippines - 2
South Korea 0
Mongolia - 0
SARS Deaths: Western Pacific and South Asia
New Zealand - 0
India - 0
How do we determine
who has SARS?
1. Signs and Symptoms:
cough
difficulty of breathing
fever (>38 C [100.4 F])
2. Chest x-ray results:
pneumonia or
acute respiratory distress syndrome
3. History of travel
within 10 days of onset of symptoms from
countries with SARS cases
4. Close contact with persons diagnosed
with SARS

SARS transmission
SARS can be transmitted from
person to person by droplet
infection.
SARS cases, when they cough, can
spread droplets with the infective
organism to a distance of
approximately one meter or three
feet.
SARS can not be transmitted by
mosquitoes or animals; Ukay-
ukay, meat, etc




How to Prevent Spread
1. Barring entry of sick passengers
at port of exit from countries with
SARS cases (i.e. China, Hong
Kong, Singapore and Vietnam)
2. Health assessment through the
Health Check List and self-
reporting among Philippine
airports
3. Triage of cases through DOH
hotline and referral to appropriate
hospital facility
Advisory on Quarantine
Persons symptomatic on arrival:
Direct to airport or maritime quarantine station
Refer to hospitals (San Lazaro or RITM or
regional hospitals)

Persons asymptomatic on arrival:
If with contact with SARS case:
Advise Voluntary Home Confinement
Limit contact with members of the household
Call DOH hotlines once signs and symptoms
indicative of SARS appear within 14 days after
arrival
If without known contact with SARS case:
Call DOH hotlines once signs and symptoms
indicative of SARS appear within 14 days after
arrival

Personal Protective Equipment
(PPE)

Cap N-95 Mask
Goggles Gown
Gloves Shoe covers
N95

The N stands for
respirator filters that can
be used when no oil is
present in the
contaminants.

The 95 means that the
product has been tested
and certified to have a
filter efficiency level of
95% or greater against
particulate aerosols.

What are the limitations
of the N-95 respirator?

The N-95 respirator has
the ability to filter
particles 1 micrometer
with a filter efficiency of
> 95%. If this respirator
becomes wet, it is no
longer effective and
must be replaced. The N-
95 is not intended for
protection from organic
vapors, toxic gases, or
toxic particulates.
Key Points
Designed to reduce the risk for occupational exposure to SARS
infection from both recognized and unrecognized sources of infection
Wear disposable gowns, gloves and goggles for close patient contact
Wash hands using liquid soap and water when leaving the anteroom
Use an 70% alcohol-based hand rub solution after hand washing
Wash hands when leaving the unit
DOH Operational Goals for SARS
1. Prevent/ Minimize entry of imported
SARS cases
2. Prevent/ Minimize local transmission
3. Prevent/ Minimize mortality from SARS
4. Educate the Public on Effective SARS
Prevention Behavior
5. Upgrade Facilities and Systems to
achieve Goals 1-4.
Strategies and Actions Taken
Prevention of Entry of SARS
Hospital Preparedness
Isolation and Containment
Public Information
Disease Surveillance
Networking
Prevention of Entry

Quarantine and Immigration

Referral of suspect SARS cases
to hospitals
Hospital Preparedness

Isolation facilities (i.e. negative
pressure rooms)
Personal protective equipment
(i.e. masks, gowns, caps, eye
shields, etc.)
Laboratory/ autopsy capabilities
Ambulance transport

Clinical Management
Finalization of the Consensus
Guideline in the Clinical Mgmt of
SARS
Triage flowchart
Orientation of hospital personnel
Briefings with WHO
Surveillance and Contact Tracing
Strengthened Epidemiology and Surveillance
Units
Get referrals from quarantine, customs
immigration, etc.
Monitoring of contacts
Triage thru SARS hotline
Data management for Bureau of Quarantine
and International Health Surveillance
Case reports and worksheets from referral
hospitals and CHDs (Regional DOH offices)
Formed Epidemiological response teams
Tarlac
Pangasinan
Cordillera
Tarlac
Metro Manila
Pampanga
Travel: April 3 to 4, 2003
Canada
Narita, Japan
Philippines
Places Visited by AC
Places Visited in
Pangasinan, Tarlac,
Pampanga and Baguio
Tarlac
Pangasinan
Cordillera
Tarlac
Metro Manila
Pampanga
Metro Manila
Tarlac
Pangasinan
Cordillera
Tarlac
Metro Manila
Pampanga
April 4, 2003 - 10:30 pm
April 5, 2003 - 5 am
April 6, 2003 - Morning
April 4 to 6, 2003
Source: NEC Operations Center
Tarlac
Pangasinan
Cordillera
Tarlac
Metro Manila
Pampanga
April 7 to 11, 2003
April 7, 2003 whole day
April 8, 2003 whole day:
San Juan; Pag-asa, QC
April 9, 2003 Bgy San
Vicente, Apalit, Pampanga
April 9, 2003 Sta.
Monica, Moncada, Tarlac
April 10, 2003 Baguio City
April 11, 2003 whole day
Source: NEC Operations Center
Contact Tracing for AC: Toronto
(NEC and Health Canada)
AC
B C A
A, B and C : Came from a visit from the Philippines; arrived in
Canada on the first week of March; stopover in Hong Kong

Same doctor as that of ESS (BLD index
case) who died of SARS on April 1, 2003;
Admitted on April 4, 2003 at the Toronto
East General Hospital; Managed initially
with Ribavarine; diagnosis unknown;
with multiple organ system failure
A and AC had history of close contact (hugging) in the
apartment of AC when 1 was already sick
B and AC are housemates in Honey Drive, Toronto, Ontario
Both were quarantined on the 2
nd
week
of March; reportedly had low grade
fever; 2 is now on her 2
nd
quarantine and
asymptomatic
C admitted on April 15, 2003 for Pneumonia
Spot Map of Bgy Vacante,
Alcala, Pangasinan
1
2
3
What to remember?
Fight SARS with SARS-I
Strengthening immune system
Avoiding contact with SARS cases
Reporting to hospitals for respiratory
difficulties for those with history of contact
with a SARS case, and for survey symptoms
and
Stay calm because symptoms of SARS cases
closely resemble those of influenza and
asthma.
I believe and transmit accurate information
Do not worry:

If you did not travel to countries with
SARS cases in February
to May 16, 2003

If you did travel to countries with
SARS cases but did not
come near a known case of SARS

PUBLIC ADVISORY
For inquiries, call:

741-7048
or
743-1937

Text Hotline:
Text SARS (space) <Message>
then send to 2960

or for Information and Updates:
Text MED(space)SARS
send to
Globe 2333
Smart 257
Thank you.