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

2. Number Of SARS Patients and HCW Infection (AS of 8/7/2003) Cases Death (%) HCW(%) Last Report Global 8422 916 11 1725(20) 7.13 China (Main) 5327 349 7 1002(19) 6.25 Guangdong 1512 58 4 346(23) 6.25 Hongkong 1755 300 17 386(22) 5.31 Taiwan 665 180 27 86(13) 6.15 Canada 251 41 17 108(43) 6.12 Singapore 283 33 14 97(41) 5.05

4. 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

5. 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

6. 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.

8. Guangzhou Super-spreader

9. 90

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

13. 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

14. 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) Fever10099.3100 Chills/rigor73.227.87451.215 Myalgia60.949.35426.545 Cough57.369.46272.775 Dyspnoea--41.72075.440 Headache55.835.42026.520 Dizziness42.84.21246.5-- Sputum29.04.9--11.5-- Diarrhoea19.623.61024.225 Nausea & vomiting19.619.420--35 Sore throat23.212.520--25 Malaise--31.25024.645 Presenting Symptoms

15. 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

16. 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%)

17. CD4 + lymphocyte 475.6 ± 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)

18. T Lymphocyte Subtypes (1)

19. T Lymphocyte Subtypes (2)

20. 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%)

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

22. 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

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

24. 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

25. 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

26. Mortality in Guangzhou Total cases 1274 Dead 46 3.61% 70% (892 cases) with IgG titer 4 times higher than normal 5.16% Mortality 46/892 = 5.16%

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

28. 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

29. Distribution of death relating to age (n=931) Age (yrs) <1515-2020-3030-4040-5050-6060-70>70Total Case1247287255161825037931 Death00151357435 %000.42.08.16.114113.7

30. Underlying Disease relating to death (n=931) TotalWith underlying disease No underlying disease Case931190 (20.4%) 741 (79.6%) Death351520 %3.77.92.7 Underlying diseases—Diabetes, COPD, chronic asthma, cancer, chronic renal disease, hypertension, pulmonary TB, chronic hepatitis, chronic heart failure, etc

31. A comparison of Intubation Rate and Crude Fatality Rate in SARS patients NCPAP(BiPAP)IntubationFatality Hong Kong 1755 35 (2.0%) 246 (14.0%) 300 (17.1%) Guangzhou 528 122 (23.1%) 39 (7.4%) 29 (5.5%) P (X 2 test) <0.001 (228.3) <0.001 (16.3) <0.001 (43.6)

32. Hospital Infection Control

33. Number Of SARS Patients and HCW Infection (AS of 8/7/2003) Cases Death (%) HCW(%) Last Report Global 8422 916 11 1725(20) 7.13 China( Main ） 5327 349 7 1002(19) 6.25 Guangdong 1512 58 4 346(23) 6.25 Hongkong 1755 300 17 386(22) 5.31 Taiwan 665 180 27 86(13) 6.15 Canada 251 41 17 108(43) 6.12 Singapore 283 33 14 97(41) 5.05

36. 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

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

41. Separated Fever Clinic

52. Thank You !