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Early Containment of Severe Acute Respiratory Syndrome (SARS); Experience from Bamrasnaradura Institute, Thailand


Achara Chaovavanich MD*, Jurai Wongsawat MD*, Scott F Dowell MD, MPH**,
Yaowarat Inthong RN*, Chariya Sangsajja MD*, Natpatou Sanguanwongse MD*,
Michael T Martin MD, MPH***, Khanchit Limpakarnjanarat MD, MPH**, Sirirat Likanonsakul MSc*,
Sunthreeya Waicharoen MSc****, Malinee Chittaganpitch MSc****, Pranee Thawatsupha BSc****,
Wattana Auwanit PhD****, Pathom Sawanpanyalert MD, DrPH****, Bjorn Melgaard MD*****

* Bamrasnaradura Institute, Ministry of Public Health (MOPH), Thailand
** International Emerging Infections Program, Thai MOPH - US CDC Collaboration, Thailand
*** HIV/AIDS Program, Thai MOPH - US CDC Collaboration, Thailand
**** National Institute of Health, Ministry of Public Health (MOPH), Thailand
***** World Health Organization, Representative to Thailand, Thailand


Background : On March 11, 2003, a World Health Organization (WHO) physician was admitted to Bamrasnaradura Institute, after alerting the world to the dangers of severe acute respiratory syndrome (SARS) in Vietnam and developing a fever himself. Specimens from the first day of his admission were among the first to demonstrate the novel coronavirus, by culture, reverse transcription-polymerase chain reaction (RT-PCR), and rising of specific antibody, but proper protective measures remained unknown. The authors instituted airborne, droplet and contact precautions from the time of admission, and reviewed the efficacy of these measures.
Material and Method : A specific unit was set up to care for the physician, beginning by roping off an isolated room and using a window fan to create negative pressure, and later by constructing a glass-walled antechamber, designated changing and decontamination areas, and adding high-efficiency particulate air (HEPA)filters. The use of personal protective equipment (PPE) was consistently enforced by nurse managers for all the staff and visitors, including a minimum of N95 respirators, goggles or face shields, double gowns, double gloves, full head and shoe covering, and full Powered Air Purifying Respirator (PAPR) for intubation. To assess the adherence to PPE and the possibility of transmission to exposed staff, a structured questionnaire was administered and serum samples tested for SARS coronavirus by enzyme-linked immunosorbent assay (ELISA). Exposure was defined as presence on the SARS ward or contact with laboratory specimens, and close contact was presence in the patientís room.
Results : The WHO physician died from respiratory failure on day 19. 112 of 129 exposed staff completed questionnaires, and the 70 who entered the patientís room reported a mean of 42 minutes of exposure (range 6 minutes-23.5 hours). 100% reported consistent handwashing after exposure, 95% consistently used a fit-tested N95 or greater respirator, and 80% were fully compliant with strict institutional PPE protocol. No staff developed an illness consistent with SARS. Serum samples from 35 close contacts obtained after day 28 had a negative result for SARS coronavirus antibody.
Conclusions : Hospitalization of one of the earliest SARS patients with documented coronavirus shedding provided multiple opportunities for spread to the hospital staff, but strict enforcement of conservative infection control recommendations throughout the hospitalization was associated with no transmission.

Keyword : SARS, Thailand, Infection control

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