Decision No. 1113/2003/QĐ-BYT on Issuing the "Provisional Guidelines for Diagnosis, Treatment, and Prevention of Severe Acute Respiratory Syndrome (SARS) Infection"

Pursuant to …;

Regarding the issuance of the "Provisional Guidelines for Diagnosis, Treatment, and Prevention of Severe Acute Respiratory Syndrome (SARS) Infection"

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THE MINISTER OF HEALTH

Pursuant to Decree No. 68/CP dated October 11, 1993 of the Government stipulating the functions, tasks, powers, and organizational structure of the Ministry of Health;

At the proposal of the Director of the Department of Treatment of the Ministry of Health;

Pursuant to …;

Article 1. Now hereby promulgating together with this Decision "Provisional Guidelines for Diagnosis, Treatment, and Prevention of Severe Acute Respiratory Syndrome (SARS) Infection".

Article 2. "Provisional Guidelines for Diagnosis, Treatment, and Prevention of Severe Acute Respiratory Syndrome (SARS) Infection" shall apply to all state, semi-state, private, non-profit, and foreign-invested medical facilities.

Article 3. This Decision takes effect from the date of issuance, replacing Decision No. 888/2003/QĐ-BYT dated March 19, 2003 on Provisional Guidelines for Diagnosis, Treatment, and Prevention of Severe Acute Respiratory Syndrome Infection and Decision No. 903/2003/QĐ-BYT dated March 21, 2003 on Supplementing and Amending Section G of Part II of the "Provisional Guidelines for Diagnosis, Treatment, and Prevention of Severe Acute Respiratory Syndrome Infection" issued by the Minister of Health.

Article 4. The Heads of the Office, Directors of the Department of Treatment - Ministry of Health, Directors of Bach Mai Hospital, Institute Directors of Clinical Tropical Medicine, Heads of Hospitals and Institutes under the Ministry with hospital beds, Directors of Provincial Health Departments, and Heads of Health Services of centrally-administered cities are responsible for implementing this Decision.

PROVISIONAL GUIDELINES

DIAGNOSIS, TREATMENT, AND PREVENTION OF SEVERE ACUTE RESPIRATORY SYNDROME (SARS) INFECTION
(Issued together with Decision No. 1113/2003/QĐ-BYT dated April 4, 2003 of the Minister of Health)

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I. DIAGNOSIS:

1.1. Epidemiology:

Patients from areas where the disease is circulating, or who have had contact with suspected SARS patients.

1.2. Clinical:

a. Onset: About one week after exposure to the source of infection.

b. General symptoms:

- Abrupt high fever, usually continuous above 38°C, sometimes with shivering, red face, rapid pulse, poor appetite, headache, muscle pain, and possibly sore throat and peripheral lymphadenopathy.⁰c. Respiratory symptoms: One or more of the following:

- Cough: Usually dry cough, occasionally productive cough when secondary infection occurs.

- Shortness of breath: Rapid shallow breathing over 25 breaths per minute (in adults).

- Signs of acute respiratory distress.

- Crackles heard on auscultation.

1.3. Ancillary clinical:

- Chest X-ray: Pulmonary lesions appear as interstitial pneumonia, initially localized then spreading, progressing rapidly day by day, in severe cases may involve both lungs completely.

- Blood gas analysis: May show severe hypoxemia with SpO2 below 90% or PaO2 below 60 mmHg; PaCO2 normal or increased.

- Blood count: Normal or decreased white blood cell and platelet counts. When there is bacterial superinfection, the white blood cell count increases.

1.4. Microbiological diagnosis:

- Perform tests to identify microorganisms (if conditions permit).

- Perform bacterial tests (sputum, bronchial secretions, blood) and antibiotic sensitivity testing.

II. TREATMENT:

2.1. Principles:

a. All cases detected must be hospitalized and isolated completely.

b. The causative agent has not been clearly identified, and there is no specific treatment available. Therefore, symptomatic treatment is mainly provided, with timely detection and management of acute respiratory distress.

c. Report all detected cases immediately to the local preventive health center and the Ministry of Health.

2.2. Symptomatic treatment:

- Use antitussives if there is persistent dry cough.

- Nasal drops with common nasal drops.

- If fever exceeds 38.5°C, administer antipyretics:

+ Adults: Use Paracetamol, dosage 2g/day, divided into four doses.

+ Children: Use Paracetamol 50-60 mg/kg body weight/day, divided into four doses.

2.3. Nutrition and electrolyte correction:

- Ensure adequate nutrition for the patient.

- Drink plenty of fruit juice.

- Intravenous infusion of 0.9% sodium chloride solution, 5% glucose, and Ringer lactate.

- The volume of fluid administered depends on the clinical course and electrolyte levels.

- Intravenous infusion of amino acid solutions.

2.4. Supportive treatment:

- Administer intravenous methylprednisolone at a dose of 1mg/kg/day when there is respiratory failure, severe infection, or poisoning, continue until signs of respiratory failure improve but not exceeding five days.

- Gamma globulin can be administered intravenously at 200-400 mg/kg, only once; or albumin 20% at 100 ml/dose, every three days if conditions permit, the number of infusions depending on the patient's health status.

2.5. Treatment of acute respiratory failure:

a. Assess the condition of acute respiratory failure through the following signs:

- Clinically:

+ Shortness of breath, rapid breathing over 25 breaths per minute (for adults). For children, determine rapid breathing based on age:

. Under 2 months: > 60 breaths per minute

. From 2 to 12 months: > 50 breaths per minute

. From 1 to 5 years: > 40 breaths per minute

+ Cyanosis of lips, extremities, or respiratory muscle retraction. In severe respiratory failure, there may be altered consciousness.

- Measure oxygen saturation through the skin: SpO2 below 90% and/or arterial blood gas PaO2 below 60 mmHg (if conditions permit).

b. Management of acute respiratory failure in adults:₂ - Principle:₂ + Ensure ventilation, provide sufficient oxygen for nasal prongs. If conditions allow monitoring SpO2 or PaO2, maintain SpO2 > 90% or PaO2 > 60 mmHg.

+ Oxygen via nasal cannula or mask. Flow rate 4-10 liters/minute for patients without pre-existing chronic lung disease; flow rate 1-3 liters/minute for patients with pre-existing chronic obstructive pulmonary disease.

- Non-invasive mechanical ventilation CPAP or BIPAP is indicated when:

+ Breathing rate over 25 breaths per minute, respiratory muscle retraction, heart rate over 100 beats per minute.₂ + SpO2 below 90% or PaO2 below 60 mmHg despite nasal cannula or mask oxygen.₂ + Blood pH: 7.3 - 7.35₂ Non-invasive mechanical ventilation can only be performed on cooperative patients with good expectoration. After 30-60 minutes of non-invasive mechanical ventilation, if the clinical condition worsens, endotracheal intubation and mechanical ventilation should be performed.₂ Invasive mechanical ventilation (endotracheal intubation and mechanical ventilation).

+ Indicated when the patient exhibits one of the following:

+ Altered consciousness, inability to expel sputum, failure of non-invasive ventilation.

+ Respiratory rate over 25 breaths per minute, respiratory muscle retraction, heart rate over 100 beats per minute.

+ SpO2 below 90% or PaO2 below 60 mmHg despite oxygen therapy via nasal cannula or mask.₂ + Blood pH: 7.3 - 7.35₂ Non-invasive mechanical ventilation may only be performed on cooperative conscious patients who can effectively cough up phlegm. After 30-60 minutes of non-invasive mechanical ventilation, if the patient's clinical condition deteriorates, endotracheal intubation and mechanical ventilation must be initiated.

Invasive mechanical ventilation (endotracheal intubation and mechanical ventilation).

+ Indicated when the patient exhibits any of the following signs:

+ Altered consciousness, inability to expel phlegm through coughing, failure of non-invasive ventilation.

down to below 60% and adjust PEEP according to blood gas analysis or SpO2.

to maintain PaO2 > 60 mmHg or SpO2 > 90%.

+ Ventilation mode: Artificial ventilation with positive end-expiratory pressure (PEEP), typically starting with FiO2 at 100% for 1 hour with PEEP +5 cmH2O, tidal volume (Vt) 6-8 ml/kg; respiratory rate 16-20 breaths/min; peak airway pressure under 45 cmH2O. Gradually decrease FiO2 down to below 60% and adjust PEEP according to blood gas or SpO2 to maintain PaO2 > 60 mmHg or SpO2 > 90%.₂ Use masks meeting standards such as N95 masks. Masks must fit tightly to the face, covering both the nose and mouth. Each mask should be used for one work shift or replaced immediately if torn or soiled. In yellow zones, N95 masks must be worn at a minimum. In green zones, everyone is advised to wear masks.₂ - Use protective gowns (paper gowns, single-use).₂ Blood pressure greater than 60 mmHg or SpO2 greater than 90%.

+ Sedatives and muscle relaxants should be administered if the patient resists the machine.

c. Treatment of acute respiratory failure in children: Refer to Appendix 1 for guidance.

2.6. Etiological treatment:

- The etiology has not been clearly identified, so there is no specific treatment. However, it is highly likely that viruses are the causative agents of this syndrome.

- Treatment of secondary bronchopulmonary infections: Use broad-spectrum third-generation cephalosporins or new-generation quinolones combined with an aminoglycoside (Refer to Appendix 2).

- Antiviral drugs: Ribavirin 800 mg/day, maximum 1200 mg/day (based on weight), divided into 3-4 doses/day taken during meals (it is necessary to monitor blood formula, liver and kidney function, and adjust dosage accordingly), continue until fever subsides for 2 days, usually from 7-10 days. Contraindicated in individuals allergic to the drug or excipients, pregnant women or nursing mothers, severe heart disease, renal insufficiency with creatinine clearance under 50 ml/min. Severe liver failure or decompensated cirrhosis, hemoglobinopathies. Women who have used Ribavirin must not become pregnant within 4 months after stopping the medication due to the risk of fetal malformations.

2.7. Monitoring

a. Clinical: Monitor pulse, blood pressure, temperature, respiratory rate, urine output.

b. Paraclinical: Chest X-ray, blood gases, creatinine, electrolytes, blood formula, CPK, liver enzymes (ALT, AST).

2.8. Criteria for discharge and post-discharge follow-up

Patients are transferred to another isolation area (buffer zone) when they meet all the following criteria:

+ Fever-free for at least 5 days without antipyretic medication.

+ Cessation of coughing.

+ Good overall condition: normal eating and sleeping.

+ Blood pressure and respiratory rate return to normal.

+ Blood tests return to normal if previously abnormal:

Blood formula, liver enzymes (ALT, AST).

+ Improvement in chest X-ray.

+ SpO2 measurement above 95%.

- Patients are treated in another isolation area (buffer zone) for 7 days, and only discharged if their condition remains stable.

- Before discharging patients, the treatment facility must notify the Standing Committee for Disease Control.

- After discharge, patients must revisit the treatment location for examination and chest X-ray check-ups once a week until the chest X-ray returns to normal. During this period, patients need to rest at home and avoid public places.

- After discharge, patients must self-monitor temperature every 12 hours, and if the temperature exceeds 38°C at two consecutive measurements or if other abnormal signs appear, they must immediately seek medical attention at the treatment location.

III INFECTION CONTROL⁰3.1. Principles

Strict implementation of isolation measures. All healthcare workers must guide suspected SARS patients to designated healthcare facilities for examination, classification, and isolation if necessary upon discovery.

3.2. Organization of Isolation Areas

There are three isolation areas based on the risk of infection in hospitals treating SARS patients:

a. High-risk area (special isolation area):

- Location for treating and caring for SARS patients or suspected SARS patients.

- This area must have a red sign reading "SPECIAL ISOLATION AREA" and detailed instructions posted at the entrance to inform everyone.- There must be guards to control entry and exit, separate pathways to different areas, and instructions on mask usage and infection prevention methods.

- The special isolation area is divided into four separate zones: examination zone, observation zone for suspected SARS patients, treatment zone for SARS patients, and buffer zone.

b. Risk area:

- An area where there is a high likelihood of SARS patients coming for initial examination and treatment. For example: Respiratory Department, Emergency Department, Outpatient Department, etc. This area must have detailed instructions posted at the entrance and exit, marked with a yellow sign.

c. Potential risk area: - Includes all remaining areas with patients. This area is marked with a blue sign.

3.3. Prevention for Patients and Visitors: - Early detection and immediate isolation of rooms for suspected cases.

- Confirmed patients must be placed in individual rooms, not sharing rooms with suspected cases.

- All SARS patients must wear standard masks such as N95, and suspected cases must wear standardized masks when inside and outside the room.

- Patients requiring imaging, testing, or specialist consultations must be conducted at the bedside. If conditions do not allow, prior notification must be given to related departments for healthcare staff to prepare appropriate protective equipment. Patients must wear masks and gowns during transportation within the hospital.

- Instruct patients to spit into disposable tissues and immediately dispose of them in medical waste bins.

- Limit family visits during outbreaks. Prohibit family members and visitors from entering isolation areas.

- Family members visiting patients outside isolation areas must wear masks.

- Hospitals should organize the sale of masks to family members of patients.

3.4. Prevention for Healthcare Workers:

- Protective equipment includes:

- Distribution and use of protective equipment:

- All personnel in the red zone (strict isolation area) must be provided with and wear full protective equipment before contact with patients and respiratory secretions at the start of their shift. After the shift ends, discard the equipment in medical waste bins and handle as infectious waste. N95 masks, protective goggles, face shields, disposable gowns, gloves, caps, shoe covers or boots.

- Mask usage: - Use masks meeting standards such as N95 type. Masks must fit tightly to the face, covering both nose and mouth. Each mask is used for one shift or replaced immediately if torn or dirty. In the yellow zone, at minimum, standardized N95 masks must be worn. In the green zone, everyone is instructed to wear masks.

- Usage of protective gowns (paper gowns, single-use). Use masks that meet the standard such as N95 masks. The mask must fit tightly to the face, covering both the nose and mouth. Each mask is for one work shift or must be replaced immediately if it tears, gets wet, or becomes dirty. In the dark yellow zone, at least the N95 standard mask must be worn. In the green zone, instruct everyone to wear a mask.

- Use protective gowns (paper gowns, single-use)Wearing protective clothing every time there is direct contact with patients, it is best to use it once. If not available, it can be reused for one work shift or discarded when soiled. Hang the outer side of the protective clothing inside when not in use. In cases where disposable clothing is not available and reusable fabric clothing must be used, disinfection, washing, and sterilization must be performed after each work shift.

- Using gloves: Use single-use gloves when coming into contact with patients, equipment, or the surrounding environment. Remove gloves after each use and immediately wash hands with soap or hand sanitizer containing alcohol >60%.

- Using protective goggles or face masks: Mandatory during procedures and direct patient care, especially when dealing with respiratory secretions (suctioning, intubation, coughing, runny nose, etc.). After each work shift, protective goggles and face masks must be disinfected using a disinfectant solution or alcohol >60%.

- Specimens for testing: Must be placed in a plastic bag or transport container as prescribed before being sent to the laboratory.

- Hand hygiene: Wash hands with soap or hand sanitizer. Wash hands after contact with respiratory secretions, patient care, dirty equipment, after removing gloves, after removing masks, before leaving the patient room - isolation area.

- Personal hygiene: Medical staff working in special isolation areas must take a shower and change clothes before leaving the hospital.

- Monitoring: Maintain a list of medical staff directly caring for and treating patients and those working in departments with SARS patients. These staff members will monitor their temperature daily. Those showing signs of suspected SARS will be examined, tested, and monitored like suspected SARS patients.

3.3. Handling medical equipment, linens, and patient supplies:

- Medical equipment: Reusable equipment must be disinfected immediately, then transferred to the washing room for cleaning and sterilization according to regulations.

- Patient supplies: Must be cleaned and disinfected with soap and disinfectants daily and whenever they become soiled. Each patient should have separate supplies for hygiene and nutrition.

- Linens: Steam under pressure before washing. Handle and process as infectious linen. Collect linens in yellow plastic bags before transporting to the laundry. Soak linens in disinfectant solutions. Add additional disinfectant concentration during washing if necessary.

3.6. Environmental and hospital waste management:

- Environment:: The patient rooms and isolation areas are considered heavily contaminated zones. Floors, baseboards, and corners of furniture must be wiped at least twice a day with disinfectants. Cleaning staff in these areas must also use personal protective equipment as medical staff. Disinfection after patient discharge shall be carried out according to the guidelines in Appendix 3. Hospital and environmental disinfection procedures in contaminated areas.

- Waste: All solid waste generated in special isolation areas is considered infectious waste. When generated, this waste must be collected immediately in yellow plastic bags, which must be securely tied and transported to the hospital's centralized waste collection point for incineration. Bags must not tear during transport, causing waste spillage.

3.7. Transporting patients:

- Non-invasive mechanical ventilation CPAP or BIPAP is indicated when:

+ Minimize patient transport.

+ Only transport patients in cases where their condition exceeds the treatment capacity of the facility.

+ Ensure safety for both patients and transport personnel (drivers, healthcare workers, family members, etc.) according to infection prevention guidelines.

- Patient transport personnel must wear full personal protective equipment:

N95 masks, disposable gowns, face shields, gloves, and hats.

- Decontaminate ambulances after each patient transport using standard disinfectants.

3.8. Handling deceased patients:

- Non-invasive mechanical ventilation CPAP or BIPAP is indicated when:

Ensure safety for staff, family members, and the community.

- Deceased patients must be embalmed on-site according to disease prevention regulations, using disinfectants such as chloramine B and formaldehyde.

- Transport deceased patients to burial or cremation sites using dedicated vehicles and ensure compliance with infection control regulations.

- Within 24 hours after death, cremation or burial must occur, preferably cremation./.