1. 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

2. 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.

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

4. 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, FEB 28, 2003
29 March: Dr. Carlo Urbani of the WHO dies of SARS

5. 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
Hong Kong
Taiwan
Canada
Singapore
USA
Viet Nam

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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)

17. 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

18. 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

19. 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

20. 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

21. 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.

22. 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

23. 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

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

25. 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

26. 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

27. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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”

41. 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

42. 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

43. Severe Acute Respiratory Syndrome Public Health – Seattle & King County SARS and Biological Disaster/Terrorism Preparedness
The influenza pandemic of 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

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

45. 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

46. Severe Acute Respiratory Syndrome Public Health – Seattle & King County

47. Questions?

48. 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:
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