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SARS Situation in Guangdong and Hospital Infection Control Xiaoping Tang, M. D, Ph. D 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(%) Number Of SARS Patients and HCW Infection (AS of 8/7/2003) Cases Death (%) HCW(%) Last Report Global 8422 916 11 1725(20) China(Main) 5327 349 7 1002(19) Guangdong 1512 58 4 346(23) Hongkong 1755 300 17 386(22) Taiwan 665 180 27 86(13) 7. 13 Canada Singapore 6. 12 251 283 41 33 17 14 108(43) 97(41) 6. 25 5. 31 6. 15 5. 05

Foshan Cases § In November, 2002 A cluster of 5 cases of Pneumonia from 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 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. • 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 Guangzhou Super-spreader

90 90

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

General Information Male 124 Female 138 Age 2 -89 years old average 41± 18 General Information Male 124 Female 138 Age 2 -89 years old average 41± 18 SARS contacting history Incubation period 175 (67. 3%) 1 -14 d average 4. 5 d

Presenting Symptoms Clinical features (%) Hong Kong Lee et al (n=138) Toronto Booth et Presenting Symptoms Clinical features (%) Hong Kong Lee et al (n=138) Toronto Booth et al (n=144) Hong Kong Peiris et al (n=50) Guangzh ou Zhang et al (n=260) Singapore Hsu et al (n=20) Fever 100 99. 3 100 100 Chills/rigor 73. 2 27. 8 74 51. 2 15 Myalgia 60. 9 49. 3 54 26. 5 45 Cough 57. 3 69. 4 62 72. 7 75 Dyspnoea -- 41. 7 20 75. 4 40 Headache 55. 8 35. 4 20 26. 5 20 Dizziness 42. 8 4. 2 12 46. 5 -- Sputum 29. 0 4. 9 -- 11. 5 -- Diarrhoea 19. 6 23. 6 10 24. 2 25 Nausea & vomiting 19. 6 19. 4 20 -- 35 Sore throat 23. 2 12. 5 20 -- 25

Laboratory Findings (1) Leucocyte >10 × 109/L 38 (14. 6%) 4. 0~10 × 109/L Laboratory Findings (1) Leucocyte >10 × 109/L 38 (14. 6%) 4. 0~10 × 109/L 146 (56. 2%) < 4. 0 × 109/L 76 (29. 2%) < 2. 0 × 109/L 35 (13. 5%) Lymphocyte < 1. 5 × 109/L 226 (86. 9%) Platelet < 10 × 109/L 25 (9%) the lowest 2. 5 × 109/L

Laboratory Findings (2) LDH increase 121 (46. 5%) CK increase 106 (40. 8%) ALT 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%)

Laboratory Findings (3) CD 4 + lymphocyte 475. 6 ± 405. 2/ul < 400/ul Laboratory Findings (3) CD 4 + lymphocyte 475. 6 ± 405. 2/ul < 400/ul 56/93 (60. 2%) < 200/ul 30/93 (32. 3%) the lowest 23/ul SO 2 < 95% 101 (38. 8%)

T Lymphocyte Subtypes (1) T Lymphocyte Subtypes (1)

T Lymphocyte Subtypes (2) T Lymphocyte Subtypes (2)

Chest X-ray Interstitial damage 184 (70. 7%) Small patch-like or spotty shadow 195 (75%) 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 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 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 • Duration Dose of methylprednisolone in Guangzhou No. 8 Hosp • Dose of MP • Duration • N=54 140± 123 mg/d (40~500 mg/d) 14± 12 days

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

Prognosis Average time of hospitalization Common type 13. 8 ± 3. 5 d Severe Prognosis Average time of hospitalization Common type 13. 8 ± 3. 5 d Severe type 28. 4 ± 10. 3 d Fatality rate 4. 2% (12/260)

Mortality in Guangzhou Total cases Dead 1274 46 3. 61% 70% (892 cases) with Mortality in Guangzhou Total cases Dead 1274 46 3. 61% 70% (892 cases) with Ig. G titer 4 times higher than normal Mortality 46/892 = 5. 16%

Low mortality in Guangdong (why? ) (1) • Misdiagnosis • Less worse epidemics – 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 referred Low mortality in Guangdong (why? ) (2) • Critical Cases • Medical staff referred to well-equipped and well-trained hospitals • Guideline - better efficacy with combined management (lower dose corticosteroid +CPAP/Bi. PAP)

Distribution of death relating to age (n=931) Age (yrs) <15 15 -20 20 -30 Distribution of death relating to age (n=931) Age (yrs) <15 15 -20 20 -30 30 -40 40 -50 50 -60 60 -70 >70 Total Case 12 47 287 255 161 82 50 37 931 Death 0 0 1 5 13 5 7 4 35 % 0 0 0. 4 2. 0 8. 1 6. 1 14 11 3. 7

Underlying Disease relating to death (n=931) Total With underlying disease No underlying disease Case Underlying Disease relating to death (n=931) Total With underlying disease No underlying disease Case 931 190 (20. 4%) 741 (79. 6%) Death 35 15 20 % 3. 7 7. 9 2. 7 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 N CPAP A comparison of Intubation Rate and Crude Fatality Rate in SARS patients N CPAP (Bi. PAP) Intubation Fatality Hong Kong 1755 35 (2. 0%) 246 (14. 0%) 300 (17. 1%) Guangzhou 528 122 (23. 1%) 39 (7. 4%) 29 (5. 5%) <0. 001 (228. 3) <0. 001 (16. 3) <0. 001 (43. 6) P (X 2 test)

Hospital Infection Control Hospital Infection Control

Number Of SARS Patients and HCW Infection (AS of 8/7/2003) Cases Death (%) HCW(%) Number Of SARS Patients and HCW Infection (AS of 8/7/2003) Cases Death (%) HCW(%) Last Report Global 8422 916 11 1725(20) China(Main)5327 349 7 1002(19) Guangdong 1512 58 4 346(23) Hongkong 1755 300 17 386(22) Taiwan 665 180 27 86(13) Canada Singapore 251 283 41 33 17 14 108(43) 97(41) 7. 13 6. 25 5. 31 6. 15 6. 12 5. 05

Medical Staff Infection in Our Hospital • Total 20 (8 doctors, 12 nurses) • 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 After Bitter Experiences More Strict Hospital Preventive Measures were Taken by Medical Staff

Separated Fever Clinic Separated Fever Clinic

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