S

EVERE
CUTE
ESPIRATORY
YNDROME
A
R
S
DINAS KESEHATAN TNI AL
PROMOSI KESEHATAN
ABDUL ROHMAN, dr, Sp.P
KOLONEL LAUT (K) NRP.8468/P
Oleh
Dr. Abdul Rohman, SpP
K-3B
Tujuan
PANIK
WASPADA
KENAL
CEGAH





JASMERAH (EPIDEMIOLOGY)
In March 2003, the WHO orchestrated a w
The virus is also shed in stool, and in one regional regional
outbreak, infection spread through an apartment complex as
consequence of defective sewage orldwide effort to control a
sudden outbreak a progessive respiratory illness termed SARS.
The first case was reported from Guangdong province of China in late
November 2002, in a health care worker. Later, he developed
pneumonia and died but the disease remained undiagnosed. In
February 2003, an infected business man traveling from China
stayed in a hotel in Hong Kong and infected 10 other individuals
staying on the same floor.
These individuals in turn spread the illness to five different countries,
including Hong Kong, Singapore, Vietnam, Thailand, and Canada.
The illness was spread primarily through air droplets in closed
spaces inluding airplanes. Family members and hospital personnel
who failed to maintain respiratory precautions were primarily
affected. system.
Pengertian SARS

KUMPULAN GEJALA
PENYAKIT INFEKSI SALURAN NAPAS
TIMBUL TIBA-TIBA
DALAM HITUNGAN HARI CEPAT PARAH
Severe Acute Respiratory Syndrome
(Sindroma Pernapasan Akut Parah)
Essential of diagnosis
Mild, moderate, or severe respiratory illness
Travel to endemic area within 10 days before
symptom onset, including mainland China,
Hongkong, Singapore Taiwan , Vietnam, and
Toronto.
Persistent fever, dry cough, dyspnea in most.
Diagnosis confirmed by antibody testing or
isolation of virus.
No specific treatment; mortality as high as 10%
in clinically diagnosed cases.




















KEY POINTS
About Severe Acute Respiratory Syndrome

1. Caused by a unique strain of coronavirus thats is spread by
aerolized droplets and is excreted in stool. Beware of super
spreaders.
2. Attacks mainly people over the age of 15 years. Most cases
occur in people 25 to 70 years of age.
3. Incubation period is 2 to 7 days. Illness occurs in 2 stages :
a). Febrile prodrome
b). Respiratory phase with infiltrate and hypoxia.
4. Diagnosis based on clinical criteria.
5. Only current treatment is meticulous supporting care.
6. Mortality is 11 % overall, and 43 % in people over 60 ys of age.
7. Strict respiratory isolation and standart contact isolation are
used to prevent transmission

PENGERTI AN SARS
KONTAK DEMAM GANGGUAN R/RDS SEROLOGI
NAPAS
TERKONTAK

DIDUGA

DIDUGA KUAT
(SUSPECT)

DIDUGA
SANGAT KUAT
(PROBABLE)

PASTI


KARIER

+
+ +
+ + +
+ + + +
+ + + +
+
+
- - - -

Penyakit akut saluran napas
Otopsi : RDS
}Etiologi ?
WHO Case Definitions for SARS
Case type Characteristics
Suspected
Fever above 38C , PLUS cough or
difficulty breathing , PLUS residence in
area with recent local transmission of
SARS within 10 days of the onset of
symptoms.
Probable
A suspected case with radiographic
findings of pneumonia or with ARDS,
OR a suspected case with a positive test
for SARS, OR a suspected case with an
unexplaned respiratory illness leading
to death with autopsy demonstrating
ARDS pathology without a defined
cause.
PENYAKI T
CEPAT (27 NEGARA) seluruh dunia
realitas di lapangan
KERAWANAN
LUAS WILAYAH
OBAT ? Pikka Aro (Pejabat ILO)
Dr. Carlo Urbani (Pakar WHO)
GLOBALISASI (ARUS LALIN MANUSIA)
PERILAKU MASY.
MASUK ANGIN
REMEH
MENOLAK : - ISOLASI
- DIRAWAT
KUMPUL
BESUK
KEWASPADAAN
realitas di lapangan
TERJANGKIT/WABAH : ?
KONTAK ERAT
SELF LIMITED (80 - 90%)
ANGKA KEMATIAN 4%
TAK SEKEJAM HIV/AIDS
HILANG DNG SENDIRINYA (KEMARAU)

r
e
a
l
i
t
a
s

d
i

l
a
p
a
n
g
a
n

SARS meski menular dengan cepat,
PENYAKIT PERKIRAAN KEMATIAN
3,7%
100%
50-90%
60% tanpa antibiotika 15% antibiotika
50%
5-15%
20%
10%
10%
SARS
HIV/AIDS
EBOLA
PES
KOLERA
DESENTRI
D B D
INFLUENZA
TIFUS
Tak sekejam
HIV/AIDS
terbukti tak mematikan ketimbang
penyakit menular lainnya.
nyaris
0,4%
Swine Flu
Single-stranded RNA coronavirus
- similar to influenza & measles
- a unique genome closely to bovine & avian
coronavirus
withstand drying, remain infectious in a warmer, moist
environment
- on average survives on surfaces & hands 3
hours
- Before SARS among the most common causes of
adult viral URI
- super spreaders - a small subset of SARS patients
were


PENYEBAB
PASTI : ? (20 MARET 2003)

MUTASI VIRUS
DARI BINATANG
Jarang pada manusia

Masa Inkubasi
2 - 7 hari
Masa Penularan
saat awal terjadinya
kesulitan bernapas
Dapat berlangsung s/d 10 hari
Mode of transmission of infectious agents
Contact : direct 2 people
indirect intermediate object
Droplet : sneezing, coughing, talking, suctioning, bronchoscopy
eyes, nose or mouth (1 2 meter)
Airbone : droplet nuclei, dust particle long period
Commom vehicle : food, water, medications, devices or
equipment
Vectorborne : mosquitoes, flies, and rats
Cara penularan
KONTAK
LANGSUNG
(BERHADAPAN)
- BICARA
- BATUK
-BERSIN
Radius 0,9-2 meter
SENTUHAN
- TEKAN TOMBOL
- PEGANG PINTU/TANGGA
Virus hidup di luar tubuh
beberapa jam
Resiko penularan
WHO :
PETUGAS KESEHATAN (30%)
PENDERITA LAIN RS
ANGGOTA KELUARGA SERUMAH
PENJAGA
TAMU
PETUGAS :
BANDARA
PELABUHAN
LINTAS BATAS
PERIODE AMAN
2 MINGGU KASUS TERAKHIR SEMBUH
Gambaran Klinik
AKUT
PARAH
KONTAK
PENDERITA
DAERAH
SALURAN NAPAS :
BATUK ; RIAK negatif
NAPAS PENDEK
SULIT BERNAPAS
HIPOKSIA
PNEUMONIA (R)
RDS
DEMAM >38C sepanjang hari
LAIN-LAIN : FLUE LIKE SYNDROME
(SAKIT KEPALA, NYERI OTOT, LESU,
NAPSU MAKAN , BINGUNG, KULIT
KEMERAHAN DAN DIARE)
Gambaran klinis
Febrile prodrome
- temp. 38C
- can be associated w/ chills & rigor
- is accompanied by headache, malaise, and myalgia
- respiratory symptoms are mild : sore throat
- rash & neurologic symptoms & signs usually absent
- GI symptoms are absent, although diarrhea some cases
The lower respiratory phase
- 3 to 7 days after the onset of symptoms
- a severe, dry, non productive cough accompanied by
dyspnea and hypoxemia.
- respiratory distress is often severe, with 10 to 20% of patients
requiring
intubation and mechanical ventilation
- a watery diarrhea some patients late in the course

Figure: Clinical picture in SARS patients
CLINICAL PICTURE IN SARS PATIENTS
Exposure to SARS Fever, headache
myalgia, sore
throat, (early
symptoms)
Nonproductiv cough
shortness of breath
~ 10% of all cases
~ < 10% of all cases ventilated
< 4% of all cases die
Incubation period Prodrome Lower respiratory phase
Severe respiratory phase
Clinical improvement
~ 1 to 2 days
~ 4 to 5 days
~ 2 to 10 days
up to 13 days
reported
~ 90% of all cases
Infectivity
None or very low Low Very high Unknown, treat as very high
PEMERIKSAAN FISIK
Tanda Pneumonia (konsolidasi)
parenkim paru
Tanda hipoksia : takikardia, takipnu
Tanda syok : nadi lemah, tekanan
darah turun, akral dingin, sianosis dll
Chest x-ray changes


- The febrile prodrome : usually normal
- The respiratory phase : change dramatically
The initial focal interstitial infiltrates that quickly
progress to more generalized, patchy infiltrates.
- The late state : these interstitial infiltrates develop
into areas of dense consolidation.


Laboratory finding
Decreased absolut lymphocyt count
Total peripheral WBC usually normal or
At the peak of the respiratory illness :
50% of the patients leucopenia & thrombocytopenia
(50,000- 150,000/L).
Muscle (SGOT) & hepatic (SGPT) enzymes often elevated
early in the resp. phase, reflecting the onset of
rhabdomyolysis & hepatitis.
Level of creatine phosphokinase as high as 3000 IU/L
Hepatic transaminase usually 2-6 times normal
Serum LDH elevated in 70% to 80%
Renal function usually remains normal
Limfopenia 90 %, lekosit bisa normal
Trombositopenia dan LDH meningkat : 80 % kasus
Aminotransferase meningkat : 78 %
Creatin kinase meningkat : 56 %

Deteksi jenis virus SARS
1. ELISA deteksi Ab hari ke-20 postinfeksi
2. IFA - deteksi Ab hari ke-10 postinfeksi
3. PCR - deteksi Gen negatip palsu : blm
tentu bukan SARS
LABORATORIUM

Model for Hospital triage of possible SARS cases
Does the patient
have a recent
history of travel to
an affected area or
close contact with
a SARS patient
Has fever (> 38C)
developed within 14
days of leaving
affected area, or
contact with known
SARS patient
ISOLATE AND INVESTIGATE
Treat as possible SARS case;
isolate / barrier nursing;
Implement local SARS plan;
notify local health authorities &
WHO country representative
about possible SARS case
Yes Yes
Provide information about SARS; treat non SARS medical illness
No
Is the patient still within known
incubation period for SARS (14
days) following travel/contact
with SARS case ?
Yes
Give information about personal surveillance for fever during
incubation period treat non SARS medical illness
No
No
Diagnosis
PASTI :
DITEMUKAN VIRUS
SEROLOGI (PCR)


ATLANTA (USA)

KONTAK
KLINIS
RNTGEN

ON CLINICAL CRITERIA

PENGOBATAN
SELF LIMITING DISEASE
SIMPTOMATIS
1. Nutrisi yang baik
2. Keseimbangan cairan dan elektrolit
3. Oksigen hipoksemia
4. Antipiretika suhu 39C
5. Antibiotika infeksi sekunder
(makrolid beta laktam or kuinolon resp)
No specific treatment


Berat Gagal napas : ICU ventilator
ribavirin iv steroid?
MANAGEMENT
Maintain oxygenation intubate and ventilate
Antibiotics CAP w/ atypical cover
Avoid therapies/interventions aerolisation : nebuliser, chest
physiotherapy, bronchoscopy, gastroscopy.
-- procedure/intervention disrupt the respiratory tract
Take the appropriate precautions intervention/therapy
Corticosteroids & ribavirin no evidence
KOMPLIKASI
Hipoksemia refrakter intubate and ventilate
Pneumotoraks tension bila PEEP diberikan
Pneumonia nosokomial
Noncardiogenic pulmonary edema (ARDS)
Upaya penanggulangan
1. PENCEGAHAN
KONTAK
AREA
KUMUH
ANGKUTAN UMUM
ORANG
ERAT / BERHADAPAN
- HINDARI
- MASKER

-PERORANGAN
-MASYARAKAT
Upaya penanggulangan
2. MENINGKATKAN DAYA TAHAN TUBUH
PERILAKU HIDUP SEHAT
GIZI
LINGKUNGAN
KEBIASAAN (TIDUR ; ISTIRAHAT)
3. SEGERA BEROBAT
PROGNOSIS
80-90 % kasus SARS : sembuh tanpa
cacat
10-20 % berat : ARDS
Angka kematian 3-4 %
Sembuh : - Tdk batuk & panas dlm 72 jam
- Lab darah normal
- Perbaikan foto dada
Harus tinggal di rumah minimal 1 minggu

a. Mencegah pasien datang ke suatu daerah atau karantina
minimal 14 hari bila sudah datang
b. Mengisi kartu waspada kesehatan (Heatlh Alert Card) bagi
semua penumpang yang tiba di Bandara, pelabuhan laut
c. Masker ( N95 or surgical mask) : pasien, petugas Kes ,
petugas lain beresiko bandara, RS, Klinik Kes dll
d. Alat perawatan sekali pakai
e. Cuci tangan sebelum dan sesudah kontak dengan pasien
f. Selalu pakai sarung tangan, pelindung mata dan baju khusus
pada petugas kes waktu periksa pasien
g. Menjaga daya tahan tbh secara alamiah dengan hidup teratur :
- Makan & minum cukup - Tidur cukup
- Gizi seimbang - Makan vitamin seperlunya
- Kerja tidak melelahkan - Dll

80-90% virus akan mati sendiri & pasien sembuh tanpa cacat
PENCEGAHAN
PREVENTION

Given the unavailability of curative therapies, infection control practices are critical for
preventing the spread this deadly infection.

All suspected cases must be placed in strict respiratory isolation.

Hospitalized patients should be placed in negative pressure room.

Respirator masks (N-95) should be worn in combination with gowns, gloves, and
protective eyewear.

Health care worker are at particularly high risk if present during intubation of an infected
patient.

In the Toronto outbreak, one case of SARS was mistakenly diagnosed as congestive heart
failure, and respiratory precautions were not instituted.

Possibly infected patients who do not require hospitalization should be instructed not leave
home until they have been asymptomatic for 10 days.
They should use separate utensils, towels, and sheets.
Contacts may leave home as long as they are asymptomatic.
Travel to area where the WHO has determined the presence of multiple active cases of
SARS should be avoided.
Lain-lain
1. U.U. R I NO : 4 / 1984
tentang
WABAH PENYAKIT MENULAR (PASAL : 14)
BARANG SIAPA DENGAN SENGAJA MENGHALANGI
PELAKSANAAN PENANGGULANGAN WABAH DIANCAM
PIDANA SELAMA-LAMANYA 1 TAHUN DAN ATAU 1 JUTA
RUPIAH
2. KEP. MENKES R I NO: 424/MENKES/SK/IV/2003
tentang
PENETAPAN SARS SEBAGAI PENYAKIT YANG
DAPAT MENIMBULKAN WABAH
DAN PEDOMAN PENANGGULANGANNYA
3. TELEGRAM KASAL NO : 003/KES/0403
tentang
WASPADA SARS
4. RUMAH SAKIT RUJUKAN DKI JAKARTA
a. PUSAT : RSPI PROF. SULIANTI SAROSO, RS
PERSAHABATAN, RSCM
b. DAERAH : RS TARAKAN, RS PASAR REBO,
RS KOJA, RS CENGKARENG
5. POSKO SARS PEMDA DKI JAKARTA
PUSDALDUKKES DINKES DKI JAKARTA
JL. KESEHATAN NO. 10 JAKARTA PUSAT TELP.
021-34835118 (HUNTING) - PELAYANAN 24 JAM


DINAS KESEHATAN
TNI AL
PROMOSI
KESEHATAN
THANK YOU
FOR YOUR
ATTENTION
ABOUT
SARS


























It is an acute highly, infectious, respiratory disease, caused by a new strain of
coronavirus, usually transmitted by droplet infection, common among adults, clinically
characterized by short incubation period, mild prodromal symptoms followed by
respiratory symptoms rich as cough, breathlessness and progressive hypoxemia. (i.e.
decreased concentration of oxygen in the arterial blood and tissue).
Attack rate is very high (about 50%) and case fatality rate is about 5%.
There is no treatment, prevention is the only intervention.
It is a new, emerging, infectious disease posing a challenge to the entire
medical faternity in the world today.



The first case was reported from Guangdong province of China in late
November 2002, in a health care worker. Later, he developed pneumonia and died but
the disease remained undiagnosed.
Later in 2003, it spread to Hongkong, Vietnam, Singapore, from where a series of
similar cases suffering from cough, fever, breathlessness were reported. This new
syndrome was designated after its symptoms as Severe Acute Respiratory Syndrome
(SARS). By August 2003, about 8422 cases were reported from 30 countries,
including Canada and USA with 916 deaths. Dr Carlo Urbani, who first identified
SARS as a global health threat and pinpointed Guangdong province of China as the
epicentre of the pandemic of SARS.

Agent factor
Coronavirus (RNA virus), closely related to common cold virus
Reservoir
Only human reservoir & no animal reservoir
Age incidence
Common among people above 25 years of age. Children are
rarely affected
Sex incidence
more among men than women
Mode of transmission
by droplet nuclei, others : fomites, touching the patients
belonging such as linen, clothes, utensil and also door-handle
of the attached bathroom, etc. contaminated with infected
droplets and touching the face, eyes, nose or mouth has
resulted in the development of the disease.
Infectious Material
the nasal or the throat secretions.
also be found in the urine and stools
Period of Infectivity
not clearly known, However, are infectious during the period
of illness


Incubation Period
2 to 7 days (Maximum 10 days)
Clinical Features
in two phases- prodromal and respiratory
- Prodromal Phase (Febrile phase)
characterized by mild to moderately high fever associated
with chills, rigors,
headache, malaise and myalgia, lasting for two to four days
- Respiratory Phase
Later, patient develops dry cough, breathlessness, features
of atypical pneumonia,
progressing to hypoxemia. About 10 to 20 % may require
intubation and mechanical
ventilation following hypoxemia. Few inspiratory crackles
may be heard. Anorexia,
confusion, muscular stiffness may also be present. Case
fatality is due to progressive
respiratory failure.
Invectigations
X-ray chest : - Febrile phase normal
- Respir phase generalized patchy
infiltration
CT Scan : ground-glass opacification in the peripheral
subpleural areas.



Hematologic findings : Lecopenia, lymphopenia ,
thrombocytopenia
Biochemical findings : Hyponatremia, hypokalemia, elevated
serum ALT level,
LDH and creatine
phosphokinase
Specific tests : Electron microscopy, culture on Vero E 6 cell
lines, Indirect
Immuno Fluoroscent tests, DNA based
PCR test.
Case Definiton for Surveillance (WHO)
A suspect case and Probable case
- A suspect case
A person presenting after 1
st
November 2002 with history
of
High fever (38C) and
Cough and difficulty in breathing and
One or more of the following features such as
- Contact with a case of SARS
- Recent travel to areas reporting SARS , within 10
days of onset of symptoms
- Residing in an affected area
-A probable case
A suspect case with radiological evidence of iniltrates
consistent with pneumonia on
chest X-ray


Treatment
There is no specific Tx for SARS, because there is no
appropriate antibiotic. The antiviral agent ribavirin in combination
with steroids have given promising results.
Prevention and Control of SARS
The key objective are :
Early detection of infection,
Containment of infection,
Personel protective attire,
Care of the environment,
Hand hygiene,
Other measures
Early Detection of Infection
IEC activities (Information Education and Communication) to
be carried out vigorously
Heightened index of suspicion among the patients giving
history of contact with SARS
patients or history of travel in SARS areas.
Segregation of symptomatics
Notification
Visual alert















.



Containment of infection
Segregation of suspected cases until diagnosis is established.
Isolation of SARS patients in designated wards, having a
negative pressure room with
attached bathroom facility.
Doors always kept closed
Prohibition of visitors.
Maximizing natural ventilation by opening the windows and also
by using exhaust fans.
Minimizing the person traffic in the hospital.
Dedicated staff to take care of the patients.
Barrier nursing is a must for all the SARS patients.
Concurrent disinfection of respiratory secretions, linen, utensils,
etc, of the patients
Treatment protocol
Personnel Protective Attire
Resp protection preferably by N-95 masks (WHO), surgical
masks, if N-95 masks not.
Eye protection
Contact disposal by use of gowns and gloves
Care of the Environment,
Disinfection of soiled linen. Safe disposal of
biohazard waste














.



Hand hygiene
This is the corner stone of prevention!!! This must be
performed following contact with a SARS case by washing with
soap and hot water or alcohol based hand rubs.
Miscellaneous Measures
Avoid the use of nebulisers, because it may cause aerolization.
Limit the movements the patients.
Place mask or gown on the patients, during their
transportation.

Instructions to House-hold Contacts
They should be vigilant for fever and respiratory symptoms.
They should strictly adopt personnel protective attire with a
special reference to hand-hygiene,
They should not touch their nose, eyes or mouth without
washing hands after touching the patients.
Disposable gloves to be used to clean the surfaces such as
table-top, door-knob, bathroom fixtures, etc.
Not to share towels, linen and clothes until they are washed
with soap and hot water.















.



SARS What we Need to Know

Future course of the outbreak.
Source of the virus.
Other modes of transmission.
Risk of transmission on aircrafts and ships.
Period of infectivity.
Explanation for age distribution.
Importance of Hypertransmitters
Role of coinfection with metapneumovirus
Optimal diagnostic test.
Effective therapy
Vaccine approaches















.



Treatment protocol suspected
SARS
Fever persists
leucopenia
thrombocytopenia
IV Cefotaxime
IV Levofloxacin
Desaturation
Oral Ribavirin 3.6 gm/day
+
Oral Prednisolone 1mg/kg/day
IV Ribavirin 1.2 gm/day
+
IV Hydrocortisone 100 mg 6
th
hrly
IV Methyl pednisolone
0.5 gm/day x 2 days
Fever persists
Chest X-ray deterioration
3
rd
or 4
th
pulse steroid
Convalescent serum therapy
Plasma exchange
X-ray chest worsening
Fever persists
F
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DINAS KESEHATAN TNI AL
PROMOSI KESEHATAN