Infection Control for SARS Patients

Mark Simmerman, RN.MS

CDC/NCID/OD

International Emerging Infections Program

SARS Case DefinitionSuspect Case

• Symptoms after 1 November 2002– Fever (>38°C) AND– Cough or shortness of breath– Diarrhea?

• Exposure within 10 days of symptoms– Traveling or living in SARS affected area OR– Close contact with SARS case

• No other explanation for respiratory disease

SARS Case DefinitionProbable Case

• Suspect case with

–Chest x-ray findings of pneumonia or respiratory distress syndrome OR

–Autopsy findings of pneumonia or respiratory distress syndrome

Close Contact

• Caring for patient with SARS

• Living with patient with SARS

• Contact with respiratory secretions or other bodily fluids of patient with SARS

Etiology: Coronavirus

• Single-stranded enveloped RNA virus

• Incubation 3-5 days

• Viremia documented

• Early evidence suggests 24+ hour survival on dry surface

• Some patients may shed virus for 30 days from onset of symptoms

• Reinfection possible

Transmission

• Droplet

• Direct contact

• Indirect contact (Fomite)

• Airborne in health care settings?

Risk to Health Care Workers (HCW)

• HCW and close contacts at highest risk

• Prince of Wales Hospital, Hong Kong

–62% (85 of 138 patients) of transmission was to HCW and medical students

• Bumrasnaradul Hospital, Thailand

–None of approximately 70 HCWs infected from a single SARS patient who died

Goals of SARS Infection Control

• Early detection

• Prompt reporting

• Containment of infection

• Protection of personnel and environment

Management of Possible Cases

1. Immediately isolate patient with

symptoms or exposure

–Place a mask on the patient

2. Personnel entering the room:

–Contact precautions

–Airborne precautions

How is SARS Spread?

• Most often by contact and droplet

- Touching patient or their secretions and then touching your face

- Having droplets from patient’s breath, speaking or coughing fall on your hands, face

• Other possible routes

- Airborne (breathing same air without mask)

Standard Precautions

• Frequent hand washing!

–Warm water and soap

–Alcohol-based hand gel ok

• Standard personal protective equipment (gloves, mask, eye protection, face shield, gown)

• Environmental control (patient care equipment, environmental hygiene, linen, trash)

• Bloodborne pathogen precautions

Contact, Droplet, and Airborne Precautions

• Minimize patient transport

• Dedicate equipment to patient if possible

• Clean/disinfect common equipment

• Use disposable equipment

• No visitors or non-essential staff

• Prepare linen on-site using protective equipment

• Private negative pressure isolation room with anteroom if possible

One Example

Glass partition

Nursing Station and Dressing Area

Entrance to anteroom

Personal protective equipment & supplies

Door to patient

room

Entrance to hallway

Anteroom

Anteroom

Negative pressure monitor

Patient room

Air Circulation

• Establish negative pressure

–Assure clean airflow

–Ensure that ventilation and windows do not open to public places

–Use fans to direct air flow

• Test negative pressure

–Use tissue paper to test air flow

–Assess airflow daily

Personal Protective Equipment

• N-95 or N-100 mask with fit testing

• Use surgical mask as second layer if mask reused

• Surgical head cover

• Goggles or face shield

–eyeglasses not adequate

• Double gown

• Double gloves

• Double shoe covers

In Dressing Area

• Put on in this order:

–N-95 mask or equivalent ! Ensure good fit

–Eye protection essential

–Head cover (all hair inside cap)

–Surgical mask as outer layer (optional)

–Shoe covers

– Inner gown (may be cloth) and gloves

–Outer gown (disposable) and gloves

In Preparation Area

• Remove in this order:

–Outer shoe covers

–Outer gown and outer gloves

–Head cover

–Surgical mask (if used)

Outside of Preparation Area

• Remove in this order:

– Inner shoe covers

– Inner gown and gloves

– Eye protection

– N-95 mask

• Evaluate reusable equipment

– Discard damaged or soiled equipment

– Clean and disinfect

– Label and hang immediately outside anteroom

• Wash hands vigorously for 2 minutes

Basic Principles• Minimize time in room

• Only essential staff

• Only one patient per room

• Minimize time within two meters of patient

• Minimize direct contact with patient

• Avoid patient’s bathroom unless essential

• Minimize equipment in patient rooms

Reducing Droplets

• Medical management to reduce cough

• Medical management to reduce vomiting

• No nebulizer treatments

• Closed suctioning of ventilated patients

• Supply oxygen dry- by nasal prongs if possible

• Patient must wear mask at all times

• Handle bed linens to avoid creating aerosols

High Risk Activities-AVOID When Possible

• Nebulized treatments

• Oxygen masks

• Noninvasive positive pressure ventilation

• Percussion chest physiotherapy

• Use of humidified oxygen

High Risk Activities – AVOID When Possible (cont’d)

• Manual bagging

• Tracheal and oropharyngeal suction

• Nasopharyngeal aspiration/ throat swab

Use nasal, not NP swab

Intubation for SARS Patients

• Elective intubation: Paralyze and Sedate!

• Closed system suctioning

• HEPA filter or exhaust to outside

• Avoid manual bagging

• Negative pressure, well-ventilated room

• Minimize number of people in room

• Most experienced staff members only

Restrict Access to SARS Ward

1. No visitors

2. No Attendants

3. No students

Fomites: Contaminated Surfaces

• Door knob

• Bedrail

• IV Pole

• Toilet

• Medical Equipment

Clean surfaces

• 5% NaOCl (Bleach)

• Sponge

• Bucket for each room

• Hot water

• Clean at least once daily

Specimen Handling

• Single bag specimens in patient’s room

• Double bag outside of patient’s room

• Label and alert laboratory of incoming specimens from SARS-infected patient

Surveillance of Health Care Workers

• Keep lists of SARS case-patients and exposed health care workers

• Exposed personnel should be followed for fever and respiratory symptoms

• Health care workers with symptoms should be evaluated & isolated if necessary

Follow-up of Discharged Patient

• Home quarantine for at least 10 days

–Temperature log, twice daily

–Return if temperature >38°C on two occasions

• Convalescent serology at 3 weeks after onset of symptoms

Conclusion

• Hand Hygiene: Frequent Washing, Gloving

• Personal Protective Equipment- Mask+ Eye Protection Always

• Minimize Contact Time

• Monitor HCWs for Symptoms

• Teach and monitor your coworkers!