SARS Situation in Guangdong and Hospital Infection Control Xiaoping Tang, M.D, Ph.D Guangzhou No. 8 People’s Hospital

Number Of SARS Patients and HCW Infection (AS of 8/7/2003) Cases Death (%) HCW(%) Last Report Global (20) 7.13 China (Main) (19) 6.25 Guangdong (23) 6.25 Hongkong (22) 5.31 Taiwan (13) 6.15 Canada (43) 6.12 Singapore (41) 5.05

Foshan Cases  In November, 2002 A cluster of 5 cases of Pneumonia from one family were hospitalized, 2 developed to RF （ First case : onset time Nov 16 ）  Large shadows in Lungs  No Response to Antibiotics X-Ray

Heyuan Cases Mr. Huang, a restaurant cook, got sick on Dec.10 in Shenzhen admitted to Heyuan 1 st Hospital on Dec.15 ， 2002 A cluster of cases including 8 HCW happened First case in Heyuan

Zhongshan Cases January 20, 20 cases were reported to Guangdong Health Bureau. Jan. 21, experts from Guangzhou, Foshan, Heyuan and China CDC had consultation together.

Guangzhou Super-spreader

90

Total Patients Received 1 st patients: Feb 2, 2003 Total : 413 probable & suspect cases (262 confirmed )

Male 124 Female 138 Age 2-89 years old average 41±18 SARS contacting history 175 (67.3%) Incubation period 1-14 d average 4.5 d General Information

Clinical features (%)Hong Kong Lee et al (n=138) Toronto Booth et al (n=144) Hong Kong Peiris et al (n=50) Guangzhou Zhang et al (n=260) Singapore Hsu et al (n=20) Fever Chills/rigor Myalgia Cough Dyspnoea Headache Dizziness Sputum Diarrhoea Nausea & vomiting Sore throat Malaise Presenting Symptoms

Laboratory Findings (1) Leucocyte >10 ×10 9 /L 38 (14.6%) 4.0~10 ×10 9 /L 146 (56.2%) < 4.0 ×10 9 /L 76 (29.2%) < 2.0 ×10 9 /L 35 (13.5%) Lymphocyte < 1.5 ×10 9 /L 226 (86.9%) Platelet < 10 × 10 9 /L 25 (9%) the lowest 2.5 × 10 9 /L

Laboratory Findings (2) LDH increase 121 (46.5%) CK increase 106 (40.8%) ALT increase 174 (66.9%) AST increase 136 (52.3%) BUN 28 (10.8%)

CD4 + lymphocyte ± 405.2/ul < 400/ul 56/93 (60.2%) < 200/ul 30/93 (32.3%) the lowest 23/ul SO2 < 95% 101 (38.8%) Laboratory Findings (3)

T Lymphocyte Subtypes (1)

T Lymphocyte Subtypes (2)

Chest X-ray Interstitial damage 184 (70.7%) Small patch-like or spotty shadow 195 (75%) Large patch-like shadow 161 (61.9%) Reticular opacities 93 (35.8%) Both lung involvement 192 (73.8%)

Management Oxygen taking Antibiotics: empirically Anti-viral reagents : Ribavirin Glucocorticoid (Methyprednisolone) Artificial Ventilator support

Corticosteroid Management Early systemic corticosteroid administration Autopsy showed: hyalinization of airway basal membrane, alveolar fibrosis (similar to ARDS) Indication: High fever>3 days Chest X ray deteriorates progressively

Dose of methylprednisolone in Guangzhou No.8 Hosp Dose of MP 140±123mg/d (40~500mg/d) Duration 14±12 days N=54

No-invasive Positive Pressure Ventilation (CPAP/BiPAP) Indications: 1. RR>30times/min ； 2.SaO 2 < 93% when taking oxygen 3-5L/min 3 、 Difficulty in breathing No.8 Hosp. N=54/262

Average time of hospitalization Common type 13.8 ± 3.5 d Severe type 28.4 ± 10.3 d Fatality rate 4.2% (12/260) Prognosis

Mortality in Guangzhou Total cases 1274 Dead % 70% (892 cases) with IgG titer 4 times higher than normal 5.16% Mortality 46/892 = 5.16%

Low mortality in Guangdong (why?) (1) Misdiagnosis Less worse epidemics – Peak < 60 newly diagnosed pts/day Age distribution ? Fewer patients with underlying diseases?

Low mortality in Guangdong (why?) (2) Critical Cases Medical staff Guideline - better efficacy with combined management (lower dose corticosteroid +CPAP/BiPAP) referred to well-equipped and well-trained hospitals

Distribution of death relating to age (n=931) Age (yrs) < >70Total Case Death %

Underlying Disease relating to death (n=931) TotalWith underlying disease No underlying disease Case (20.4%) 741 (79.6%) Death % Underlying diseases—Diabetes, COPD, chronic asthma, cancer, chronic renal disease, hypertension, pulmonary TB, chronic hepatitis, chronic heart failure, etc

A comparison of Intubation Rate and Crude Fatality Rate in SARS patients NCPAP(BiPAP)IntubationFatality Hong Kong (2.0%) 246 (14.0%) 300 (17.1%) Guangzhou (23.1%) 39 (7.4%) 29 (5.5%) P (X 2 test) <0.001 (228.3) <0.001 (16.3) <0.001 (43.6)

Hospital Infection Control

Number Of SARS Patients and HCW Infection (AS of 8/7/2003) Cases Death (%) HCW(%) Last Report Global (20) 7.13 China( Main ） (19) 6.25 Guangdong (23) 6.25 Hongkong (22) 5.31 Taiwan (13) 6.15 Canada (43) 6.12 Singapore (41) 5.05

Medical Staff Infection in Our Hospital Total 20 (8 doctors, 12 nurses) Happened during the time when there were most patients ( from Feb. 12 to Feb.19 ) All recovered

After Bitter Experiences More Strict Hospital Preventive Measures were Taken by Medical Staff

Separated Fever Clinic

Thank You !