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SARS: Interim Guidelines for Severe Acute Respiratory Syndrome

CDC issued its first health alert regarding severe acute respiratory syndrome (SARS) on March 15, 2003. Since that time the Vermont Department of Health has been working to keep healthcare workers informed of the latest development and performing case-finding for possible cases in Vermont. Two Vermont residents have been identified as being suspected cases of SARS after arrival from endemic regions in Southeast Asia. Both had mild disease and did not need to be hospitalized.

The following are CDC recommendations as of April 7, 2003. These recommendations are subject to change as more information becomes available. We urge you to keep yourself informed with the latest developments; check the CDC SARS website at http://www.cdc.gov/ncidod/sars/.

Case Definition

The case definition for suspected SARS is subject to change, particularly concerning travel history; the most current definition can be accessed at http://www.cdc.gov/ncidod/sars/casedefinition.htm.

Respiratory illness of unknown etiology with onset since February 1, 2003, meeting the following three criteria:

• Measured temperature greater than or equal to 100.5 °F/38° C AND
• One or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, hypoxia, or radiographic findings of either pneumonia or acute respiratory distress syndrome) AND
• Travel within 10 days of onset of symptoms to an area with documented or suspected community transmission of SARS (see list below; excludes areas with secondary cases limited to healthcare workers or direct household contacts)

OR:

• Close contact within 10 days of onset of symptoms with either a person with a respiratory illness who traveled to a SARS area or a person known to be a suspect SARS case. Close contact is defined as having cared for, having lived with, or having direct contact with respiratory secretions and/or body fluids of a patient known to be a suspect SARS case.

Areas with Documented or Suspected Community Transmission of SARS

Peoples’ Republic of China (i.e., Mainland China and Hong Kong Special Administrative Region); Hanoi, Vietnam; and Singapore

Causative Agent

CDC reports that there is mounting evidence that a newly detected coronavirus as the most likely cause of SARS, but this is not yet confirmed. Coronaviruses are a common cause of mild to moderate upper-respiratory illness in humans and are responsible for approximately one third of common colds.

Mode of Transmission

Large respiratory droplets and direct contact appear to be the predominant modes of transmission; airborne and fomite transmission may also play a role. Although symptomatic individuals are infectious, it is not known how long before or after symptoms begin that patients with SARS might be able to transmit the disease to others.

Reporting

Notify the Vermont Department of Health @ 802-863-7240 or 800-640-4374 immediately of any patients who meet the above definition. Direction will be given on specific laboratory specimens for transport to CDC.

Clinical Presentation

The incubation period is typically 2 to 7 days (although a few cases suggest an incubation period up to 10 days). The illness generally begins with fever, often associated with chills and rigors and might be accompanied by other symptoms, including headache, myalgias and malaise. Some patients have mild respiratory symptoms at the onset of illness. At day 3 to 7 of illness, a respiratory phase begins, with non-productive cough and/or dyspnea, which may progress to cause hypoxia that is severe enough to require endotracheal intubation in approximately 10% to 20% of cases.

Chest radiographs are often normal during the febrile prodrome (and may remain so during the entire illness), but interstitial infiltrates, both local and generalized, may be seen during the respiratory phase. Consolidations can be seen on chest radiographs obtained in the later stages of SARS.

Complete blood counts may reveal a normal (or sometimes decreased) total white blood cell count, but the absolute lymphocyte count is often decreased. During the peak of the respiratory phase, leukopenia and thrombocytopenia (50,000 – 150,000/ul) is seen in approximately half of patients.

Other laboratory abnormalities include elevated creatine phosphokinase (as high as 3,000 IU/L) and hepatic transaminase levels (2 to 6 times the upper limit of normal). In most patients, renal function has remained normal.

The course of SARS has been highly variable, ranging from mild, self-limited illness to death. The case-fatality rate among persons meeting the current case definition of SARS is approximately 3%. The case definition being used for surveillance purposes in the United States is detecting many cases with milder illness than what has been reported internationally. As of April 4, 2003, there were no deaths reported in the United States. The majority of close contacts to SARS cases remain well, although some have reported a mild febrile illness without a respiratory component and others have developed SARS. Most secondary cases have occurred among healthcare workers who were not using adequate infection control precautions.

Triage and Screening

Healthcare workers who are the first point of patient contact (e.g., triage nurses) should be trained to recognize a potential case of SARS by screening individuals with fever and respiratory symptoms for:

• Travel to the People’s Republic of China, Hong Kong Special Administrative District, Hanoi, Vietnam or Singapore within the 10 day period prior to symptom onset OR
• Contact with someone with possible SARS within the 10-day period prior to symptom onset.

A surgical mask should be placed on any patient meeting these criteria. Some facilities have found it helpful to, place a box of masks by the entrances likely to be used by persons seeking care, and a notice asking that persons with respiratory symptoms don a mask before they approach the triage nurse.

Healthcare workers should implement Standard, Contact and Airborne Precautions. When available, place the patient in an airborne infection isolation room, i.e.: negative pressure room, and use of N-95 (or equivalent) disposable particulate respirators. When particulate respirators are not available, healthcare workers evaluating and caring for a patient with suspect SARS should wear a surgical mask.

Diagnosis/Evaluation of Patients

Along with other appropriate tests for the patient’s condition, CDC recommends that initial diagnostic testing should include chest radiograph, pulse oximetry, blood cultures, sputum Gram’s stain and culture, and testing for viral respiratory pathogens, notably influenza A and B and respiratory syncytial virus (RSV). Clinicians should save any available clinical specimens (respiratory, blood, and serum) for additional testing until a specific diagnosis is made. CDC will perform testing for the newly identified coronavirus when the patient meets the clinical case definition for SARS. Please contact VDH to arrange this testing.

Refer to http://www.cdc.gov/ncidod/sars/specimen_collection_sars2.htm for collection and handling of specimens from suspect SARS cases.

Treatment

There are no recommendations for specific treatment. There have been anecdotal reports of ribavirin with or without corticosteroids being used. For severely ill patients, consultation with infectious disease specialists or the CDC can be arranged.

Infection Control Guidelines for Patients with Suspected SARS in the Outpatient Setting

If a suspect SARS patient is evaluated in an outpatient setting, the following infection control measures should be followed until ten days after the resolution of respiratory symptoms:

• Targeted screening questions concerning fever, respiratory symptoms, recent travel and exposure to a SARS case should be included at triage or as soon as possible after patient arrival.
• A surgical mask should be placed on suspect SARS patients; they should be placed in a private room as soon as possible with the door kept closed. A room that has negative air pressure and/or HEPA filtration capabilities, or with a portable HEPA filtration unit, would be preferable.
• Contact precautions (e.g., gown and gloves) with eye protection should be implemented.
• Health care personnel should wear an N-95 respirator while in the same room with a suspect SARS patient; if an N-95 respirator is not available, a surgical mask should be worn.

Additional guidance regarding SARS infection control in the ambulatory care setting is available at http://www.cdc.gov/ncidod/sars/ic.htm

Management of Household Contacts

Patients with SARS pose a risk of transmission to close household contacts. The duration of time before or after onset of symptoms during which a patient with SARS can transmit the disease to others is unknown, however patients are currently being asked to follow these isolation measures while they are symptomatic and for ten days following resolution of respiratory symptoms. The following infection control measures are recommended for patients with suspected SARS in households or residential settings.

• SARS patients should limit interactions outside the home and should not go to work, school, out-of-home childcare, or other public areas until ten days after resolution of fever and respiratory symptoms. During this time, infection control precautions should be used, as described below, to minimize the potential for transmission.
• All members of a household with a SARS patient should carefully follow recommendations for hand hygiene (e.g., frequent hand washing or use of alcohol-based hand rubs), particularly after contact with body fluids (e.g., respiratory secretions, urine, or feces).
• Use of disposable gloves should be considered for any direct contact with body fluids of a SARS patient. However, gloves are not intended to replace proper hand hygiene. Immediately after activities involving contact with body fluids, gloves should be removed and discarded and hands should be cleaned. Gloves must never be washed or reused.
• Each patient with SARS should be advised to cover his or her mouth and nose with a facial tissue when coughing or sneezing. If possible, a SARS patient should wear a surgical mask during close contact with uninfected persons to prevent spread of infectious droplets. When a SARS patient is unable to wear a surgical mask, household members should wear surgical masks when in close contact with the patient.
• Sharing of eating utensils, towels, and bedding between SARS patients and others should be avoided, although such items can be used by others after routine cleaning (e.g., washing with soap and hot water). Environmental surfaces soiled by body fluids should be cleaned with a household disinfectant according to manufacturer’s instructions; gloves should be worn during this activity.
• Household waste soiled with body fluids of SARS patients, including facial tissues and surgical masks, may be discarded as normal waste.
• Persons who may have been exposed to SARS should be vigilant for fever or respiratory symptoms. At this time, in the absence of fever or respiratory symptoms, household members or other close contacts of SARS patients need not limit their activities outside the home. Household members or other close contacts of SARS patients who develop fever or respiratory symptoms should seek healthcare evaluation. When possible, in advance of the evaluation, healthcare providers should be informed that the individual is a close contact of a SARS patient. Household members or other close contacts with symptoms of SARS should follow the same precautions recommended for SARS patients. For information on guidance see http://www.cdc.gov/ncidod/sars/exposuremanagement.htm

Additional guidance regarding SARS close contact in households is available at

http://www.cdc.gov/ncidod/sars/ic-closecontacts.htm

Infection Control Guidelines for Patients with Suspected SARS in the Inpatient Setting

If a suspect SARS patient is admitted to the hospital, the following infection control measures should be followed:

• Standard precautions (e.g. hand hygiene). For all contact with suspect SARS patients, careful hand hygiene is required, including hand washing with soap and water; if hands are not visibly soiled, alcohol-based handrubs may be used as an alternative to hand washing.
• Eye protection should be worn for all patient contact.
• Contact precautions (e.g. use of gown and gloves for contact with the patient or their environment).
• Airborne precautions (e.g., an airborne isolation room with negative pressure. Personnel entering the room should wear N-95 respirators.
• The patient should be provided with a surgical mask during triage, transport to an airborne isolation room or during transport out of the room for medical tests or procedures.

If airborne precautions cannot be fully implemented, patients should be placed in a private room with the door closed and a portable HEPA filter. If N-95 particulate respirators are not available, surgical masks should be worn. Other information on appropriate infection control precautions for patients with suspected SARS can be found at http://www.cdc.gov/ncidod/sars/ic.htm

Management of Unprotected Exposures among Healthcare Personnel

Transmission to healthcare workers appears to have occurred after close contact with symptomatic individuals (e.g., persons with fever or respiratory symptoms) before recommended infection control precautions for SARS were implemented. Given the currently available information on the epidemiology of SARS in the United States, the following outlines interim guidance for the management of exposures to SARS in a healthcare facility.

• Exclusion from duty is recommended for a healthcare worker if fever or respiratory symptoms develop during the 10 days following an unprotected exposure to a SARS patient.
• Exclusion from duty should be continued for 10 days after the resolution of fever and respiratory symptoms. During this period, infected workers should avoid contact with persons both in the facility and in the community
• Exclusion from duty is not recommended for an exposed healthcare worker if he/she does not have either fever or respiratory symptoms.
• Workers with unprotected exposure who develop symptoms should not report for duty, but should stay home and report symptoms to the designated person within the facility or to the Vermont Department of Health

Additional guidance on exposure management for healthcare workers can be accessed at the CDC website http://www.cdc.gov/ncidod/sars/exposureguidance.htm

Hospital Visitors

Close contacts (e.g., family members) of SARS patients are at risk for infection. Close contacts with either fever or respiratory symptoms should not be allowed to enter the hospital as visitors and should be educated about this policy. Keep in mind that persons close to the individual could have had a common source exposure and may be incubating the disease; ask about travel history in these people. Visitors should be educated about use of infection control precautions when visiting SARS patients and their responsibility for adherence to them.

Related Information

• More On SARS From CDC