Public Health - Seattle & King County Severe Acute Respiratory Syndrome (SARS): Lessons Learned for (Biological) Emergency Preparedness Jeffrey S. Duchin, M.D. Chief, Communicable Disease Control, Epidemiology, & Immunization Section Public Health - Seattle & King County Assistant Professor in Medicine, Division of Allergy and Infectious Diseases, University of Washington

Severe Acute Respiratory Syndrome Public Health - Seattle & King County Chronology 11 FEB: WHO “working to learn more” about an outbreak of severe respiratory illness in Guangdong Province, China ongoing since 16 November Affected “hundreds” of persons 30% of cases reportedly among health care workers On 17 FEB: a 33 y.o. man who traveled with his family from Fujian Province in China died in a Hong Kong hospital. An 8 y.o. daughter died in Fujian, and an 9 y.o son was ill in Hong Kong. Influenza A (H5N1) isolated from the man and his son.

Severe Acute Respiratory Syndrome Public Health - Seattle & King County Chronology

Severe Acute Respiratory Syndrome Public Health - Seattle & King County Chronology FEB 28th 2003: SARS identified in Vietnam after Dr. Carolo Urbani, epidemiologist, WHO Hanoi office, examined a patient with a severe atypical pneumonia of unknown etiology at the French Hospital in Hanoi [17 March: First SARS investigation in King County] 28 March: Chinese authorities conclude SARS outbreak is related to the outbreak in China Report 792 suspected/probable cases in Guangdong province NOV 16, 2002-FEB 28, 2003 29 March: Dr. Carlo Urbani of the WHO dies of SARS

Severe Acute Respiratory Syndrome Public Health - Seattle & King County Chronology 11 July: 8,437 cases (813 deaths) reported to WHO from 29 countries: Country Cases Deaths China 5327 348 Hong Kong 1755 298 Taiwan 671 84 Canada 250 38 Singapore 206 32 USA 75 0 Viet Nam 63 5

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Question at Annual Meeting of Prestigious Medical Subspecialty Society During SARS Outbreak How many in the audience are clinical health care providers? EVERYONE raises their hands How many in the audience are part of the local public health system? NO ONE raises their hand Most clinicians (still) do not consider themselves part of the public health system

Severe Acute Respiratory Syndrome Public Health – Seattle & King County SARS Investigations Approximately 140 investigations of possible SARS cases 18 of the 140 initially classified as suspect SARS cases; subsequently reclassified to 7 cases after laboratory testing Over 156 contact investigations related to suspect SARS cases One suspect SARS case in a health care worker exposed to a suspect SARS patient During March-April, public health received 104 to 232 calls per week (3-6 calls per hour) from the public and health care providers in King county

Severe Acute Respiratory Syndrome Public Health – Seattle & King County SARS Investigation Steps Screen reports of febrile respiratory illness among travelers and their contacts for SARS case definition criteria Interview the patient, family, contacts, physician(s) Review medical records Monitor cases under voluntary isolation until 10 days after resolution of fever and respiratory symptoms Identify and monitor exposed health care workers

Severe Acute Respiratory Syndrome Public Health – Seattle & King County SARS Investigation Steps Monitor other exposed close contacts (home, workplace, traveling companions, etc) Follow-up SARS investigation and disease control measures if symptoms develop Recommend appropriate isolation, infection control measures, lab testing and follow-up for cases and exposed persons Determine case classification, report to state and CDC Ensure submission of appropriate laboratory tests, track results Requires tracking patients over time for acute and convalescent sera

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Local Public Health Impact Approximately 16 FTE working full-time on SARS response Medical epidemiologist, disease investigation staff, epidemiologists, public health nurses, program managers/administrators Health educators, community outreach staff, communications team Need dedicated staff to ensure appropriate diagnostic specimens obtained and processed correctly for laboratory testing Administrative support

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Local Public Health Outbreak Response - Lessons Rapidly identify and mobilize necessary resources (human and logistical) Have epidemiology outbreak response plan Clearly identify tasks, job assignments; communication, etc Cross-train epidemiology and disease investigation staff Catalogue all staff and their job skills Plan to rapidly train staff recruited for emergency response

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Local Public Health Outbreak Response - Lessons Implement incident command system early to engage resources Senior administration Technical program leads Emergency manager Procurement/grants & contracts Communications team Clinical services and nursing services Environmental health Legal advisor Decide when to cease routine operations to divert resources towards outbreak response

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Local Public Health Outbreak Response - Lessons Investigations are complicated, stressful and time consuming Take into account when planning staffing needs and support services Required “specialization” of epidemiology functions with designated staff for: Phone inquiries Screening and categorizing preliminary reports Case investigations Case classification Contact tracing and follow-up Monitoring of persons under quarantine and/or isolation Case follow up Hospital and health care worker investigations and monitoring of exposed persons

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Local Public Health Outbreak Response - Lessons Hospital liaison extremely valuable Designated field teams desirable for interviews, monitoring of cases, obtaining and/or transporting laboratory specimens Specialized data collection tools and databases are needed Must be developed rapidly, “on-the-fly” Monitor cases through resolution of the communicable period Contact surveillance Tracking persons under isolation and quarantine Tracking laboratory specimens Advance preparation may be valuable

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Local Public Health Response - Lessons High demand for information from the public and impacted organizations (business community, educational institutions), first responder agencies (police, fire, EMS) Requires enhanced communications capacity Phone banks and trained staff to answer calls Hotline messages/web site EOC Health educators/spokespersons Value of pre-existing relationships and communications channels

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Surveillance/Case Identification - Lessons Required “new approach” to management of febrile persons with respiratory symptoms in ambulatory care settings Priority: Implement effective screening and triage procedures to rapidly identify potential cases in ambulatory care settings and hospitals Required “systems” approach to surveillance at health care facilities rather than depending on specific individuals (physicians or ICNs)

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Surveillance/Case Identification - Lessons Implications for surveillance for other communicable diseases Influenza Measles Pertussis Varicella Tuberculosis Meningococcal disease Smallpox and others

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Surveillance/Case Identification - Lessons Benefit of on-site surveillance liaison at health care facilities Health care facilities require functional systems and databases to: Track exposures to both health care workers and patients Monitor health care workers for development of symptoms Track visitors to high-risk patients

Severe Acute Respiratory Syndrome Public Health - Seattle & King County CDC Surveillance Case Definition: Clinical Criteria Asymptomatic or mild respiratory illness Moderate respiratory illness Temperature >100.4°F (>38° C) AND One or more clinical findings of respiratory illness (e.g. cough, shortness of breath, difficulty breathing, hypoxia Severe respiratory illness One or more clinical findings of respiratory illness (e.g. cough, shortness of breath, difficulty breathing, hypoxia) AND Radiographic findings of either pneumonia or ARDS, or Autopsy findings consistent with ARDS or pneumonia in the absence of an identifiable cause

Severe Acute Respiratory Syndrome Public Health - Seattle & King County CDC Surveillance Case Definition: Epidemiological Criteria Travel (including transit in an airport) within 10 days of onset of symptoms to an area with current or recently documented or suspected community transmission of SARS Areas with current documented or suspected community transmission of SARS according to CDC: None currently listed

Severe Acute Respiratory Syndrome Public Health - Seattle & King County CDC Surveillance Case Definition: Epidemiological Criteria Close contact within 10 days of onset of symptoms with a person known or suspected to have SARS infection. Close contact is defined as having cared for or lived with a person known to have SARS, or having a high likelihood of direct contact with respiratory secretions and/or body fluids of a patient known to have SARS. Examples of close contact include kissing or embracing, sharing eating or drinking utensils, close conversation (<3 feet), physical examination, and any other direct physical contact between persons. Close contact does not include such activities such as walking by a person or sitting across a waiting room or office for a brief period of time.

Severe Acute Respiratory Syndrome Public Health - Seattle & King County CDC Surveillance Case Definition: Laboratory Criteria Confirmed Detection of antibody to SARS-CoV in specimens obtained during acute illness or >28 days after illness onset, or Detection of SARS-CoV RNA by RT-PCR confirmed by a 2nd PCR assay by using a 2nd aliquot of specimen and different PCR primers, or Isolation of SARS-CoV Negative Absence of antibody to SARS-CoV in convalescent serum obtained >28 days after symptom onset Undetermined Laboratory testing either not performed or incomplete

Severe Acute Respiratory Syndrome Public Health - Seattle & King County CDC Surveillance Case Definition: Case Classification Probable case: Meets clinical criteria for severe respiratory illness of unknown etiology with onset since February 1, 2003, and Meets epidemiological criteria Laboratory criteria confirmed, negative, or undetermined Suspect Case: Meets clinical criteria for moderate respiratory illness of unknown etiology with onset since February 1, 2003, and Meets epidemiologic criteria

CDC: Interim Domestic Guidance on Persons Who May Have Been Exposed to Patients with Suspected Severe Acute Respiratory Syndrome (SARS), May 7, 2003

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Surveillance/Case Identification - Lessons Health care providers and clinicians need real time access to public health recommendations and guidelines Current case definition Recommendations for management of persons who may have been exposed to SARS: criteria for 72- and 144-hour isolation Incorporate revisions to case definition and 72- and 144-hour isolation guidance as clinical and epidemiologial (exposure) criteria evolve Systems used to communicate this information for SARS outbreak can serve as the basis for future emergencies or should be evaluated and improved to meet anticipated local needs

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Surveillance/Case Identification - Lessons Expectations of both public health staff and key partners should be realistic Complicated, evolving, stratified case definition with clinical, epidemiological and laboratory criteria should be expected with new diseases Anticipate “over sensitive” case definitions and corresponding implications for disease control and surveillance May not be able to rely on laboratory testing to guide clinical and epidemiological/disease control activities Highlights importance of accurate, thorough epidemiological information for case identification and management

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Surveillance/Case Identification - Lessons Optimal when clinicians know when to report and/or seek consultation with public health Early: upon suspicion, not confirmation Frequently most useful when patient still present Requires easy access 24/7 to public health health system Clinicians should know the infection control consultant and/or hospital epidemiologist and how to contact them 24/7 Many clinicians do not have this information readily available Having a designated public health assignee (outbreak liaison) at hospitals and other clinical sites can help facilitate surveillance, disease control activities and communication

Severe Acute Respiratory Syndrome Public Health - Seattle & King County Infection Control - Lessons SARS disproportionately affected hospital staff (great feature for BT agent) compounding its impact on the health care system Hospitals served as settings for amplification of transmission leading to community spread Unrecognized cases played an important role in disease transmission in some locations Infection control measures are the most important component of SARS management and prevention

Severe Acute Respiratory Syndrome Public Health - Seattle & King County Infection Control - Lessons Need to rapidly identify potential cases of public health significance and implement appropriate disease control steps Health care workers need to be knowledgeable about current and evolving infection control procedures and PPE guidelines Guideline for Isolation Precautions in Hospitals and Guidelines for Infection Control in Health Care Personnel Standard precautions Contact precautions Droplet precautions Airborne precautions

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Infection Control & Exposure Management - Lessons Significant difference in infection control resources and capacity between hospitals and ambulatory care facilities Need to enhance capacity of community clinics and ambulatory care facilities Public health system must be prepared to respond when hospitals and the health care system become casualties

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Infection Control & Exposure Management - Lessons Other communicable disease requiring airborne precautions Tuberculosis Measles Varicella (including disseminated zoster) Smallpox

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Infection Control & Exposure Management - Lessons Other communicable diseases requiring droplet precautions Invasive meningococcal disease Mycoplasma pneumonia Pertussis Certain Group A streptococcal infections Adenovirus Influenza Mumps Rubella Parvovirus B19 Pneumonic plague Smallpox

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Infection Control & Exposure Management - Lessons Other communicable disease requiring contact precautions Multi-drug resistant bacterial infections Certain enteric infections Zoster and other skin infections Viral hemorrhagic fever Smallpox

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Role of Clinicians in a Public Health Emergency Need to have designated local clinical experts as spokespersons to communicate with the public (media) and other clinicians Clinicians need to be knowledgeable about, and accurately disseminate, rapidly changing information Case definition (clinical, epidemiological, laboratory criteria) Infection control and exposure management recommendations for both the clinical and home settings Travel advisories and alerts Laboratory testing: appropriate samples, processing, interpretation Treatment and prevention guidelines Specialists should be engaged as local subject matter experts Reinforce the public health message

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Communication - Lessons CDC guidelines may not be sufficient to meet local needs May need to develop more detailed local recommendations based on CDC guidance Need for rapid dissemination of information, including the continually evolving guidelines and recommendations to: Public health staff Physicians and other health care professionals Infection control practitioners Emergency medical services Air medical transport

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Communication - Lessons Need for rapid dissemination of information, including the continually evolving guidelines and recommendations to: Public At-risk populations (i.e. departing and arriving travelers) “Hard-to-reach” populations (non-English speaking, homeless, institutionalized, etc) Businesses, organizations, schools Media Need robust health education capacity for clinical and non-clinical audiences

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Communication - Lessons Special challenge reaching non-English speaking populations Urgent need for translations: authoritative central source Need to identify and train bilingual public health staff for outreach work Found that many community members were not aware of public health resources such as web site or telephone hotline Some health care providers not “plugged in” to public health communication system or resources including CDC Need to respond aggressively to misinformation leading to prejudice and discrimination

Public Health - Seattle & King County Severe Acute Respiratory Syndrome Communication - Lessons Information to hospitals, health care providers, the public Health advisories by broadcast fax and listserv Conference calls with hospital infection control teams SARS information signs for King County clinical facilities in English, Chinese, Vietnamese, and Spanish Community outreach staff: Chinese, Vietnamese, English Information on hospital association and public health website In-person education/training for clinicians 24/7 availability to clinicians Media interviews

Severe Acute Respiratory Syndrome Public Health - Seattle & King County Isolation & Quarantine Restriction of movement and/or separation of persons ill with a contagious disease Usually in a hospital setting, but can also be at home or in a dedicated isolation facility Quarantine Restriction of movement and/or separation of well persons presumed exposed to a contagious disease Usually at home, but can be in a dedicated quarantine facility Individual(s) or community/population level Isolation & quarantine Measures usually voluntary, but can be mandatory. Legal quarantine authority exists at federal, state and local levels and covers isolation” and “quarantine”

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Isolation and Quarantine - Lessons Isolation & quarantine Rely on patients to comply with voluntary isolation request Issued voluntary isolation request letter to all SARS cases Have template letters available Critical importance of patient education by physician regarding need for compliance with isolation and with infection control recommendations Requires access to current versions of isolation requests, printed instructions and guidelines, Q & A, etc., for patients and exposed persons

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Isolation and Quarantine - Lessons Be prepared to implement widespread use of isolation and quarantine Need to establish efficient procedures for ordering mandatory isolation/quarantine, including legal process and tracking system Need to develop procedures for enforcement of isolation and quarantine orders Plan for management & supervision of persons under quarantine Teams to monitor and provide for the needs of persons under isolation and quarantine and their dependants, including social and psychological support Plan for dedicated isolation & quarantine facility

Severe Acute Respiratory Syndrome Public Health – Seattle & King County SARS and Biological Disaster/Terrorism Preparedness The influenza pandemic of 1918-19 killed more humans than any other disease in a period of similar duration in the history of the world. Alfred W. Crosby America’s Forgotten Pandemic - The Influenza of 1918 Cambridge University Press, 1989

SARS and Biological Disaster/Terrorism Preparedness Deaths By Week due to Pneumonia & Influenza October, 1918 through March, 1919 - Philadelphia, PA Population: 1,761,371 Total deaths: 15,785

Severe Acute Respiratory Syndrome Public Health – Seattle & King County Summary SARS is a local problem, as are all outbreaks and emergencies Lessons learned during the SARS outbreak are applicable to other biological emergencies and outbreaks, including smallpox Clinicians are on the front line as public health responders: we need to acknowledge it even if they don’t Individual patient care and the public health response are closely related and inter-dependant Overall success containing SARS (and other emergencies) measured by sum of local successes and failures The worst may be yet to come

Severe Acute Respiratory Syndrome Public Health – Seattle & King County

Questions?

Public Health - Seattle & King County Communicable Disease Control, Epidemiology & Immunization Section Contact us for additional information and to report suspected cases. Communicable disease report/consultation line and after-hours emergencies: 206-296-4774 Web Site: http://www.metrokc.gov/health/