Guidelines issued to doctors for SARS Contingency Action

 

What is SARS?

SARS (Severe Acute Respiratory Syndrome) is a respiratory illness that has recently been reported in Asia, North  America, and Europe

Cause of SARS

Scientists at CDC and other laboratories have detected a previously unrecognized corona virus in patients with SARS.

 WHO gave definitive confirmation on 16 April 2003 that a new pathogen, a member of the coronavirus family never previously seen in humans, is the cause of Severe Acute Respiratory Syndrome (SARS). Identification of the coronavirus means that scientists can now move towards developing treatments for SARS and successfully controlling this disease.

Coronaviruses are a group of viruses that have a halo or crown-like (corona) appearance when viewed under a microscope. These viruses are a common cause of mild to moderate upper-respiratory illness in humans and are associated with respiratory, gastrointestinal, liver and neurological disease in animals. Coronaviruses can survive in the environment for as long as three hours.

Corona viruses have occasionally been linked to pneumonia in humans, especially people with weakened immune systems.

The viruses can also cause severe disease in animals, including cats, dogs, pigs, mice, and birds.

Initial diagnostic testing for suspected SARS patients 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. A specimen for Legionella and pneumococcal urinary antigen testing should also be considered. Clinicians should save any available clinical specimens (respiratory, blood, and serum) for additional testing until a specific diagnosis is made. Acute and convalescent (greater than 21 days after onset of symptoms) serum samples should be collected from each patient who meets the SARS case definition. Paired sera and other clinical specimens can be forwarded through State and local health departments for testing at CDC. Specific instructions for collecting specimens from suspected patients are available.

Tests

No “test” is available yet for SARS; however, CDC, in collaboration with WHO and other laboratories, has developed 2 research tests that appear to be very promising in detecting antibodies to the new corona virus. CDC is working to refine and share this testing capability as soon as possible with laboratories across the United States and internationally.


 

symptoms and signs of SARS

The illness usually begins with a fever (measured temperature greater than 100.4°F [>38.0°C]). The fever is sometimes associated with chills or other symptoms, including headache, general feeling of discomfort, and body aches. Some people also experience mild respiratory symptoms at the outset.

After 2 to 7 days, SARS patients may develop a dry, nonproductive cough that might be accompanied by or progress to the point where insufficient oxygen is getting to the blood. In 10% to 20% of cases, patients will require mechanical ventilation.

The incubation period for SARS is typically 2-7 days. however, isolated reports have suggested an incubation period as long as 10 days. The illness usually begins with a fever (>100.4°F [>38.0°C])

Medical treatment recommended for patients with SARS?

 CDC currently(1/4/03) recommends that patients with SARS receive the same treatment that would be used for any patient with serious community-acquired atypical pneumonia of unknown cause.

 Several treatment regimens have been used for patients with SARS, but there is insufficient information at this time to determine if they have had a beneficial effect.

Reported therapeutic regimens have included antibiotics to presumptively treat known bacterial agents of atypical pneumonia.      

Therapy also has included antiviral agents such as oseltamivir or ribavirin. 

Steroids also have been administered orally or intravenously to patients in combination with ribavirin and other antimicrobials.

How is SARS spread?

 The principal way SARS appears to be spread is through droplet transmission; namely, when someone sick with SARS coughs or sneezes droplets into the air and someone else breathes them in. It is possible that SARS can be transmitted more broadly through the air or from objects that have become contaminated.

Information to date suggests that people are most likely to be infectious when they have symptoms, such as fever or cough. However, it is not known how long before or after their symptoms begin that patients with SARS might be able to transmit the disease to others.

1.    Cases of SARS continue to be reported primarily among people who have had direct close contact with an infected person, such as –     

r    those sharing a household with a SARS patient

r    and health care workers who did not use infection control procedures while caring for a SARS patient.         

It is not so far declared as communicable diseases in USA

Passengers who reached home from an infected area/ having contact with an infected person should be advised as follows-

1.    If you are ill with a fever of over 100.4°F [>38.0°C] that is accompanied by a cough or difficulty in breathing or that progresses to a cough and/or difficulty in breathing, you should consult a health care provider.

2.    To help your health care provider make a diagnosis, tell him or her about any recent travel to regions where cases of SARS have been reported and whether you were in contact with someone who had these symptoms.


 

prevent transmission of SARS in households?

 Infection control precautions should be continued for SARS patients for 10 days after respiratory symptoms and fever are gone. SARS patients should limit interactions outside the home and should not go to work, school, out-of-home day care, or other public areas during the 10-day period.

r During this 10-day period, all members of the household with a SARS patient should carefully follow recommendations for hand hygiene, such as frequent hand washing or the use of alcohol-based hand rubs.

r Each patient with SARS should cover his or her mouth and nose with a tissue before sneezing or coughing. If possible, a person recovering from SARS should wear a surgical mask during close contact with uninfected persons. If the patient is unable to wear a surgical mask, other people in the home should wear one when in close contact with the patient.

Disposable gloves should be considered for any contact with body fluids from a SARS patient. However, immediately after activities involving contact with body fluids, gloves should be removed and discarded, and hands should be washed. Gloves should not be washed or reused, and are not intended to replace proper hand hygiene.

SARS patients should avoid sharing eating utensils, towels, and bedding with other members of the household, although these items can be used by others after routine cleaning, such as washing or laundering with soap and hot water

r Common household cleaners are sufficient for disinfecting toilets, sinks, and other surfaces touched by patients with SARS, but the cleaners must be used frequently.

r Other members of the household need not restrict their outside activities unless they develop symptoms of SARS, such as a fever or respiratory illness.

Are there any travel restrictions related to SARS?

r At this time there are no travel restrictions in place that are directly related to SARS.

r  However, a CDC travel advisory recommends that individuals who are planning nonessential or elective travel to mainland China, Hong Kong, Hanoi, Vietnam, or Singapore may wish to postpone their trip until further notice.

 

Case Definitions for Surveillance of Severe Acute Respiratory Syndrome (SARS)

Objective

To describe the epidemiology of SARS and to monitor the magnitude and the spread of this disease, in order to provide advice on prevention and control.

Case definitions (revised 1 April 2003)

The case definitions for global surveillance are subject to limitations because of the rapidly evolving nature of this illness. They are based on current understanding of the clinical features of SARS and the available epidemiological data, and may be revised as new information accumulates. Preliminary clinical description of Severe Acute Respiratory Syndrome summarizes what is currently known about the clinical features of SARS. Countries may need to adapt case definitions depending on their own disease situation. Retrospective surveillance is not expected.

Suspect case

1.    A person presenting after 1 November 20021 with history of:

  l high fever (>38 °C)

       AND

       l    cough or breathing difficulty

       AND one or more of the following exposures during the 10 days prior to onset of symptoms:

       l close contact2 with a person who is a suspect or probable case of SARS;

       l history of travel, to an affected area 3 

       l residing in an affected area 3

2.    A person with an unexplained acute respiratory illness resulting in death after 1 November 2002, 1but on whom no autopsy has been performed

       AND one or more of the following exposures during to 10 days prior to onset of symptoms:

       l close contact,2 with a person who is a suspect or probable case of SARS;

       l history of travel to an affected area 3 

       l residing in an affected area 3 

Probable case

1.    A suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (RDS) on chest X-ray (CXR).

2.    A suspect case with autopsy findings consistent with the pathology of RDS without an identifiable cause.

Exclusion criteria

A case should be excluded if an alternative diagnosis can fully explain their illness.

Reclassification of cases

As SARS is currently a diagnosis of exclusion, the status of a reported case may change over time. A patient should always be managed as clinically appropriate, regardless of their case status.

l A case initially classified as suspect or probable, for whom an alternative diagnosis can fully explain the illness, should be discarded.

l A suspect case who, after investigation, fulfil the probable case definition should be reclassified as “probable”.

l A suspect case with a normal CXR should be treated, as deemed appropriate, and monitored for 7 days. Those cases in whom recovery is inadequate should be re-evaluated by CXR.

l Those suspect cases in whom recovery is adequate but whose illness cannot be fully explained by an alternative diagnosis should remain as “suspect”.

l A suspect case who dies, on whom no autopsy is conducted, should remain classified as “suspect”. However, if this case is identified as being part of a chain transmission of SARS, the case should be reclassified as “probable”.

l If an autopsy is conducted and no pathological evidence of RDS is found, the case should be “discarded”.

 

1       The surveillance period begins on 1 November 2002 to capture cases of atypical pneumonia in China now recognized as SARS. International transmission of SARS was first reported in March 2003 for cases with onset in February 2003.

2       Close contact: having cared for, lived with, or had direct contact with respiratory secretions or body fluids of a suspect or probable case of SARS.

3       Affected area: an area in which local chain(s) of transmission of SARS is/are occurring as reported by the national public health authorities.