Decision No. 888/2003/QÐ-BYT on the issuance of the "Provisional Guidelines for Managing Severe Acute Respiratory Syndrome"

DECISION OF THE MINISTER OF HEALTH

Regarding the issuance of the "Provisional Guidelines for Managing Severe Acute Respiratory Syndrome"

________________________

THE MINISTER OF HEALTH 

Pursuant to Decree No. 68/CP dated 11/10/1993 of the Government stipulating the functions, tasks, powers, and organizational structure of the Ministry of Health;

At the proposal of the Director of the Treatment Department,

DECISION: 

Article 1. The "Provisional Guidelines for Managing Severe Acute Respiratory Syndrome" attached hereto are hereby issued.

Article 2. This Decision takes effect from the date of issuance.

Article 3. The "Provisional Guidelines for Managing Severe Acute Respiratory Syndrome" shall apply to all state-owned, semi-state-owned, private, community-established medical facilities, and those with foreign investment.

The Heads of the Office, Directors of the Treatment Department, Inspectorate, Heads of other Departments and Bureaus under the Ministry of Health, Directors of hospitals directly under the Ministry of Health, Directors of Provincial and Municipal Health Services, and Heads of health sectors are responsible for implementing this Decision. The Heads of the Office, Directors of the Treatment Department - Ministry of Health, Directors of Bach Mai Hospital, Directors of the Clinical Tropical Medicine Institute, Heads of hospitals and institutes under the Ministry, Provincial Health Directors  of centrally governed cities, and Heads of health sectors are responsible for implementing this Decision.

PROVISIONAL GUIDELINES FOR MANAGING SEVERE ACUTE RESPIRATORY SYNDROME

(Attached to Decision No.:  888/QD-BYT

dated March 19, 2003 of the Minister of Health)

I. Diagnosis

1. Epidemiological:  Note:

 Having contact with patients admitted to Vietnam-France Hospital or areas with outbreaks.

Having contact with individuals suspected of having acute respiratory infection with fever.

2. Clinical:

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

b. General symptoms:

Abrupt high fever, often continuous above 38°C, sometimes accompanied by shivering, flushed face, rapid pulse, loss of appetite.

Headache, muscle pain in limbs, back muscles, exacerbated by coughing, may have pain around the eyes, peripheral lymph nodes may be enlarged. c. Respiratory symptoms: one or more of the following:

Cough: Usually dry cough, some cases have productive cough.

Rapid shallow breathing, respiratory rate may exceed 25 breaths per minute, accompanied by signs of acute respiratory distress.

Lung auscultation reveals moist rales, wheezing, or crackles.

3. Ancillary clinical:

Chest X-ray: lung lesions typically start in one lobe and spread to both sides, progressing rapidly day by day, potentially leading to total bilateral lung opacity and acute respiratory distress syndrome (ARDS).

Blood gas analysis: Severe hypoxemia, SpO2 below 90% or PaO2 below 60 mmHg; may also be accompanied by increased CO2 or not.

Blood count: Normal or low white blood cell and platelet counts. In bacterial superinfection, white blood cell count increases, normal or left shift.

4. Microbiological diagnosis:

Where conditions permit, perform tests to identify microorganisms.

Conduct bacteriological tests when there is suspicion of bacterial superinfection of the bronchi and lungs.

II. Management

A. Principles:

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

2. For mild cases without complications, symptomatic treatment is primarily focused.

3. Immediately report all detected cases to the local preventive healthcare center and the Ministry of Health.

B. Symptomatic treatment:

 1. Cough: Use antitussive medication if there is persistent dry cough.

2. Nasal congestion, nasal obstruction: Use common nasal drops.

3. Fever:

Loosen clothing and cool down with wet towels.

If fever exceeds 38.5°C, administer antipyretics:

Adults: give Paracetamol, dosage 2g/day, divided into 4 doses.

Children: give Paracetamol 50-60 mg/kg body weight/day, divided into 4 doses.

4. Nutrition, fluid and electrolyte balance adjustment:

Ensure adequate nutrition for the patient.

Drink plenty of fruit juice, add salt to it.

Administer intravenous solutions such as Sodium Chloride 0.9%, Glucose 5%, Ringer lactate.

The volume of intravenous fluids depends on clinical progression and electrolyte levels. Administer intravenous amino acid solutions.

5. Supportive treatment:

Intravenous Methylprednisolone at a dose of 1mg/kg/day for 3 days in case of severe respiratory failure.

Gamma globulin can be administered intravenously at 200-400 mg/kg/day for 2-5 days if conditions permit.

C. Management of acute respiratory failure

1. Assess the severity of respiratory failure through signs:

Clinical:

Difficulty breathing, rapid breathing over 25 breaths per minute (for adults). For children, determine rapid breathing based on age-specific rates:

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 retractions. In severe respiratory failure, there may be altered consciousness.

Measure oxygen saturation via pulse oximetry: SpO2 below 90% and/or arterial blood gas measurement PaO2 below 60 mmHg (if available).

2. Management of acute respiratory failure in adults:

a. Principle: Ensure ventilation, provide sufficient oxygen to the patient. If SpO2 and PaO2 measurements are available, maintain SpO2 ≥ 90% or PaO2 ≥ 60 mmHg.

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

c. Non-invasive mechanical ventilation (CPAP or BIPAP) is indicated when:

Breathing rate exceeds 25 breaths per minute, intercostal retractions, heart rate over 100 beats per minute.

SpO2 below 90% or PaO2 below 60 mmHg despite oxygen therapy via nasal cannula or mask.

Blood pH: 7.3-7.35

Non-invasive mechanical ventilation should only be performed on conscious, cooperative patients who can effectively clear secretions. After 30-60 minutes of non-invasive mechanical ventilation, if the clinical condition does not improve, endotracheal intubation and mechanical ventilation should be initiated.

d. Invasive mechanical ventilation (endotracheal intubation and mechanical ventilation) is indicated when the patient exhibits one of the following:

Altered consciousness, inability to clear secretions.

Heart rate over 110 beats per minute, systolic blood pressure below 90 mmHg.

SpO2 below 90% despite appropriate oxygen therapy.

Breathing rate less than 10 breaths per minute or more than 35 breaths per minute.

Severe metabolic acidosis: pH below 7.25.

Or failure of non-invasive mechanical ventilation.

Ventilation mode: positive end-expiratory pressure (PEEP) mechanical ventilation, typically starting with FiO2 100% for 1 hour with PEEP +5 cmH2O, tidal volume 6-8 ml/kg; respiratory rate 16-20 breaths per minute; peak airway pressure below 45 cmH2O. Gradually reduce FiO2 to below 60% and adjust PEEP according to blood gas or SpO2 to maintain PaO2 ≥ 60 mmHg or SpO2 ≥ 90%.

Sedatives may be used if the patient resists the ventilator.

3. Management of acute respiratory failure in children:

For children, follow the pediatric acute respiratory failure protocol.

D. Monitoring

1. Clinical: monitor pulse, blood pressure, temperature, respiration, urine output.

2. Ancillary clinical: chest X-ray, blood gas analysis, creatinine, electrolytes, blood count.

E. Etiological treatment

The etiology has not been clearly identified, so there is no specific treatment. However, a virus may be the cause of this syndrome.

The causative agent has not been clearly identified, therefore there is no specific treatment. However, a virus may be the cause of this syndrome.

If there is suspicion of bronchopneumonia superinfection, broad-spectrum new antibiotics effective against common bacteria and atypical bacteria causing lower respiratory tract infections should be used according to local experience and bacterial sensitivity levels.

In places with appropriate conditions, one of the following antiviral drugs may be used under the prescription and supervision of a specialist doctor:

Amantadine (MANTALIX tablets 100mg) can be administered at a dose of 5 mg/kg/day for children aged 1-9 years; for individuals aged 10-64 years, two tablets daily divided into two doses; for those aged 65 and above, one tablet daily (renal function must be monitored and dosage adjusted accordingly).

Alternatively, Ribavirin (REBETOL 200mg) can be taken four tablets daily divided into two doses during meals (blood formula, liver and kidney functions must be monitored and dosage adjusted accordingly).

Or Oseltamivir 75 mg twice daily can be given to patients over 18 years old if conditions permit.

G. Discharge Criteria

Patients are eligible for discharge when they meet all of the following criteria:

Having no fever for at least five days without antipyretic medication.

Functional status has returned to normal, overall condition is good, eating and sleeping normally.

Blood test results have returned to normal.

Chest X-ray shows stable or improved lung lesions within 48 hours after fever subsides.

A follow-up examination is required once a week after discharge. Immediate re-examination is necessary if any abnormal signs appear.

H. Disease Control

During an outbreak, early detection of suspected cases, particularly among individuals exposed to the mentioned epidemiological factors, must be prioritized.

1. Isolation of Patients Upon Detection:

Patients must be placed in a separate area and wear masks.

Visits from family members should be limited.

All visitors must be closely monitored, wearing hats, masks, and gloves. Family members staying to care for the patient must also wear masks, hats, gloves, and hospital attire.

Chloramine B 5% solution basins must be placed at the entrance of each ward for everyone entering or leaving to wash their hands.

A cloth soaked in Chloramine B or formaldehyde should be laid on the floor before the entrance for everyone to step on.

2. Healthcare Workers:

Masks, hats, and gloves must be worn when examining patients and working in the hospital. Hands must be washed after examining patients.

Protective goggles and gloves must be worn during procedures.

Change clothes before leaving the hospital.

3. Management of Medical Waste:

Strict adherence to the Ministry of Health's regulations on medical waste management must be ensured.

I. Patient Transport

Limit patient transportation.

Transport patients only when their condition exceeds the treatment capacity of the facility.

When transporting patients, safety principles for both the patient and transport personnel (drivers, healthcare workers, family members, etc.) must be followed as outlined in the disease control section.

K. Handling of Deceased Patients According to Principles Ensuring Safety for Healthcare Workers, Family Members, and the Community.

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

The deceased must be transported to cremation or burial sites using dedicated vehicles and in compliance with disease control regulations.

Cremation or burial must occur within 24 hours after death. Cremation is preferred. If burial is chosen, it should be deep./.