臨床病理科 SARS基本認識與防護措施 甯孝真

Severe Acute Respiratory Syndrome (SARS) The earliest known case of SARS came from Guandong Province in mainland China as early as November 2002. First recognized in Feb 2003 (case in Hanoi) A form of Atypical Pneumonia Mycoplasma,Legionella,Chlymydia,Viral, Chemical Characteristics - high fever (>38°C or 100.4° F) - dry cough - breathing difficulties - rapid deterioration

SARS Background 26 Feb 2003 1st case Hanoi WHO official - Dr. Carlo Urbani died 29 Mar 2003 with SARS

Coronaviruses Single-stranded RNA, nonsegmented, enveloped, ~31,000 NTs 2 serogroups (229 E and OC43) in humans ~1/3 of common colds Reinfections are common 3 known groups of coronavirus are associated with a variety of disease of human and animals gastoenteritis and upper/lower respiratory tract disease canine,feline,porcine,bovine,avian,turkey,rat

Coronavirus:Etiology of SARS ?

Genetic Evidence for Coronavirus

Use of laboratory methods for SARS However, until standardized reagents for virus and antibodies detection are available and methods have been adequately field tested, SARS diagnosis remains based on the clinical and epidemiological findings Molecular Test Conventional RT-PCR, real time PCR Cell Culture Antibody Tests

Molecular Test (PCR) Confirmation of positive PCR at least 2 (different) clinical specimens (NP or stool) or same clinical specimen collected on 2 or more days or 2 different assays or repeat PCR A PCR-kit for SARS is commercially available, including internal controls Sensitivity of PCR tests for SARS depends on the specimen and the time of testing during the course of the illness different primers

Copies/mL Ultracentrifuge 2 mL plasma

Viral Culture (BSL-3 Activities) Vero E6 support virus replication Other cell lines being evaluated May be isolated from sputum, kidney, or oropharyngeal swab Isolation rate not high CPE was first noted at 5th post inoculation focal, round CPE,quickly spread within 24-48 hrs

Coronavirus in culture

Antibody Tests of SARS ELISA (Enzyme Linked ImmunoSorbant Assay): detecting a mixture of IgM and IgG antibodies in the serum of SARS patients, positive results reliably at around day 21 after the onset of illness. IFA (Immunofluorescence Assay): a test detecting IgM or IgG antibodies IgM positive after about day 10 of illness. Antibodies detected as early as 14 days in some cases Positive: NegPositive IFA 4X  ELISA 

No. of case of SARS worldwide (1) From: 1 Nov 2002 To: 2 May 2003, 17:00 Country Cumulative no. of case(s) No. of deaths No. recovered Local transmission Australia 4 None Brazil 2 Bulgaria 1 Canada 149 22 93 Yes China 3,799 181 1,372 China, Hong Kong Special Administrative Region 1,611 170 878 China, Macao Special Administrative Region China, Taiwan 100 8 25 France 5 Germany 7 Indonesia Italy 9 Kuwait Malaysia 6 3

No. of case of SARS worldwide (2) From: 1 Nov 2002 To: 2 May 2003, 17:00 Country Cumulative no. of case(s) No. of deaths No. recovered Local transmission Mongolia 8 4 Yes New Zealand 1 None Philippines 3 2 Poland Republic of Ireland Republic of Korea Romania Singapore 203 25 146 South Africa Spain Sweden Switzerland Thailand 7 5 United Kingdom 6 United States 56 24 Viet Nam 63 Total 31 6,054 417 2,643

Symptoms of Respiratory Illness Frequency Fever 100% Chills 92% Malaise 90% Headache 84% Myalgia 67% Cough 50% Dizziness 49% Rigors 44% Sore throat 43% Runny nose 39% Productive cough 36%

Clinical Features of the Canadian Patients with SARS at Presentation published at www.nejm.org on March 31, 2003

Epidemiology Person – Person Primarily adults – 25 – 70 Transmission Person – Person Health Care Workers Community Transmission Primarily adults – 25 – 70 Uncommon < 15 years old Most Cases Resolve ~90%+ day 6-7 Mortality ~ 4-6 %

Hong Kong

Common Symptoms Hong Kong

Serum Chemistry Hong Kong Elevated LDH 71% Elevated CPK 32% median 126 U/L, range: 29-4644 Elevated ALT 23% Hypokalemia 25% Hyponatremia 20%

23.2% to ICU

Associated with tissue damage

How does SARS spread? Droplets infectious when there are symptoms, which only appear after the incubation period of 2-16 days. Droplets - via close contact with an infected person airborne? Contaminated working surfaces ~ survival up to 6 (24) hours

Administrative Communication Educate Policies & procedures Enforcement

Personal Protective Measures Mask Gloves and gowns Eye protection Hand hygiene

Guideline for wearing facemask posted on the Department of Health website on 28/03/2003 Wash hands before wearing a facemask. Follow the instructions on the packet carefully, if available. In general, when wearing a surgical facemask, the following should be noted: the facemask should fit snugly over the face; the colored side of the facemask should face outside; tie all the strings that keep the facemask in place or fix the rubber bands of the facemask round the ears properly; the facemask should fully cover the nose, mouth as well as the chin; the metallic wire part of the facemask should be fixed securely over the bridge of the nose to prevent leakage; under general circumstances, the surgical mask should be changed daily.

Blood Specimens for Routine Testing Use universal precautions Wear appropriate PPE Disposable gloves Lab coat Eye/face shields Use safe centrifugation practice Use sealed centrifuge cups or rotors Use respiratory protection when unloading centrifuge N-95 mask (surgical mask if not available)

部門成本代號 組別 作業內容 原編制人數 非第一現人員(組長或行政人員) 4/28～5/4 平均排休人數 工讀生 需求人數 39200 抽血組檢體收發及科務組 收送疑似SARS檢體 第一線抽血作業 39 9 5 30 39220 急生化鏡檢及血液組   夜間細菌接種及SARS檢體血液檢查 SARS檢體痰液抹片檢查 49 3 10 36 19200 台北檢驗組 細菌接種及培養 18 1 13 39260 微生物組 結核菌接種及培養 3.5 12.5 39250 病毒組 病毒培養 痰液等快速鑑定 7 2(研究助理) 39230 血清組 SARS血液檢體非典型肺炎抗體檢查 4H200 兒檢組 SARS檢體血液檢查 SARS檢體痰液抹片 2.5 6.5 39240 血庫組 第二線 19 39270 分子診斷組 39280 試劑研發組 6 38D00 品管醫檢師 2 00810 教學品管醫檢師 合計 181 50 28 110

Prevention of Respiratory Tract Infection (1) Building good body immunity by having a proper diet, regular exercise and adequate rest, reducing stress and avoiding smoking; Maintain good personal hygiene, and wash hands after mask removing ,sneezing, coughing or cleaning the nose; Maintain good ventilation;

疑似SARS呼吸道檢體處理注意事項 操作必須在有Class II的生物安全操作箱的隔離室內操作。 操作人員必須穿粉紅色隔離衣，外套丟棄式隔離衣，戴N95口罩，丟棄式手術頭套及雙層丟棄式手套，丟棄式腳套。 操作完後之廢棄物應置24小時尿桶，外套耐高壓滅菌袋，脫下第一層手套，緊密封口後， 移出生物安全箱。 以75% 酒精或 5% Terralin 擦拭生物安全箱及周圍環境。 離開隔離室，應在緩衝區脫下丟棄式隔離衣，N95口罩、丟棄式手術頭套及丟棄式腳套後才到一般實驗室

疑似SARS檢體處理注意事項 一、  處理前:由行政組負責收檢，首先檢查包裝及運送方式是否依照規定，若有任何未依規定的情況應立即通知相關單位宣導正確包裝及運送方式，但檢體仍需處理不退件 規定如下: 1)    穿戴雙層手套及N95或手術用口罩，檢查包裝及運送方式 2)    所有檢體及檢驗單都應貼上警告標示(EX: S 當心感染) 3)    檢體以組為單位，每組檢體應以兩層夾鏈袋包裝(同一組的可以包在同一個夾鏈袋中) 4)  同一個病患的所有檢體於包裝後，再以一個乾淨有蓋貼有警告標示(EX: S 當心感染)的塑膠容器(EX:2000 CC尿桶)包裝，將檢驗單置於桶中後送檢 5)    請勿再使用其他任何東西包裝，EX:手套、尿杯、紙箱 6)  將各組檢體分至各組，唯需轉送兒童醫院的檢體仍需使用乾淨有蓋貼有警告標示(EX: S 當心感染)的塑膠容器(EX:2000 CC尿桶)包裝 7)    凡處理完檢體皆需洗手並更換手套

疑似SARS檢體處理注意事項 二、 處理中: １）穿戴雙層手套及N95或手術用口罩，將夾鏈袋打開取出檢驗單及檢體 二、   處理中: １）穿戴雙層手套及N95或手術用口罩，將夾鏈袋打開取出檢驗單及檢體 ２）將檢體先以75%酒精消毒 ３）核對、編號、收件皆與一般檢體規定相同 ４）固定使用一台離心機離心，血液:使用BECKMAN GS-6，尿液: 使用KUBOTA-KN70 ５）檢體離心需等機台完全停止才可開蓋子，開蓋前應戴安全面罩 ６）檢體開蓋應使用厚紗布墊著，儘可能以原管上機避免分裝，最好同一個人完成檢驗操作，避免太多人接觸檢體

疑似SARS檢體處理注意事項 處理後: １）所有接觸過疑似SARS檢體的紗布、手套、CUP、吸管、尿液試紙、殘渣定量盤----等物品都應集中丟棄在乾淨有蓋貼有警告標示(EX: S 當心感染)的塑膠容器(EX:2000 CC尿桶) ，需滅菌處理方可丟棄 ２）似SARS檢體(生化、CBC、體液)於操作後原蓋蓋回，另外集中放置在乾淨有蓋貼有警告標示(EX: S 當心感染)的塑膠容器(EX:2000 CC尿桶)，冰箱保存，待病毒組來收 ３）尿液檢體一律使用MIDITRON操作，於離心後上清液倒入裝有1%漂白水的廢液桶，浸泡一天即可倒入水槽丟棄 ４）BLOOD GAS檢體於操作後、針頭丟入裝有1%漂白水的容器中，浸泡一天即可丟入廢棄針頭桶中一起處理，針筒則比照紗布、手套處理方式 ５）當處理完疑似SARS檢體後應立即以1%漂白水擦拭桌面、擦拭離心機、洗手並更換新手套 ６）所有裝有WASTE　BOTTLE的機台，需在BOTTLE加裝1%漂白水 ７）所有操作過疑似SARS檢體的機台，應視機台特性增加以1%漂白水或75%酒精的消毒步驟EX:擦拭PROBE或SAMPLE　TRAY ８） 夜間種菌時若是疑似SARS的痰液檢體皆不予處理，待第二天微生物組處理 ９）敬請所有同仁確實依照規定執行，並祝大家身體健康，全體國人平安渡過SARS危機

口罩雖阻隔了臉容， 卻阻不了人與人間慰問、微笑、寬容… 讓我們一起對抗SARS! ~ The End ~