TOC  | ID    Severe Acute Respiratory Syndrome   (SARS)

Severe Acute Respiratory Syndrome   (SARS)
CDC Resource on SARS
http://www.cdc.gov/ncidod/sars/index.htm  |  CDC Fact Sheet on SARS for Public  |  FAQ aout SARS  |  U.S.  Cases of SARS  
WHO (World Health Organization) Resource on SARS
http://www.who.int/csr/sars/en/   |   FAQ about SARS  |  World Cases of SARS
MMWR Resource on SARS
http://www.cdc.gov/mmwr/PDF/wk/mm5212.pdf  
Univ. of  HongKong Resource on SARS  |  Management Guideline  
California Med Association Resource on SARS  
Los Angeles County Public Health SARS  Info
Medscape Resource on SARS   |  Yahoo Resource on SARS  
NEJM Resource on SARS  
NEJM  March 31, 2003  A Cluster of Cases of Severe Acute Respiratory Syndrome in Hong Kong  
NEJM March 31, 2003  Identification of Severe Acute Respiratory Syndrome in Canada    |  Editorial  
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Case Definitions for Surveillance of Severe Acute Respiratory Syndrome (SARS)  from WHO  
Case Definitions for Surveillance of Severe Acute Respiratory Syndrome (SARS)

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 of SARS  

  1. A person presenting after 1 November 20021 with history of:
    -      high fever (>38 °C or 100.4 °F), AND
    -  cough or breathing difficulty, AND one or more of the following exposures during the 10 days prior to onset of symptoms:
    -  close contact2 with a person who is a suspect or probable case of SARS;
    -  history of travel, to an affected area 3
    -  residing in an affected area 3
  2. A person with an unexplained acute respiratory illness resulting in death after 1 November 2002,
    1    but on whom no autopsy has been performed , AND one or more of the following exposures during to 10 days prior to onset of symptoms:
    -  close contact,2     with a person who is a suspect or probable case of SARS;
    -   history of travel to an affected area 3
    -  residing in an affected area 3

Probable case of SARS

  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.
-   A case initially classified as suspect or probable, for whom an alternative diagnosis can fully explain the illness, should be discarded.
-   A suspect case who, after investigation, fulfil the probable case definition should be reclassified as "probable".
-   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.
-   Those suspect cases in whom recovery is adequate but whose illness cannot be fully explained by an alternative diagnosis should remain as "suspect".
-   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".
-   If an autopsy is conducted and no pathological evidence of RDS is found, the case should be "discarded".

Suspect Case of SARS  
A person presenting after 1 February 2003 with history of :

Probable Case of SARS

Comments
In addition to fever and respiratory symptoms, SARS may be associated with other symptoms including:
headache, muscular stiffness, loss of appetite, malaise, confusion, rash, and diarrhea.

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* Close contact is defined as having cared for, having lived with, or having had direct contact with respiratory secretions and /or body fluids of a patient suspected of having SARS.

List of areas with documented or suspected community transmission of SARS: Hong Kong Special Administrative Region and Guangdong province, Peoples' Republic of China; Hanoi, Vietnam; and Singapore

Note: Suspect cases with either radiographic evidence of pneumonia or respiratory distress syndrome; or evidence of unexplained respiratory distress syndrome by autopsy are designated "probable" cases by the WHO case definition.

Diagnosis/Evaluation          
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. Clinicians should save any available clinical specimens (respiratory, blood, and serum) for additional testing until a specific diagnosis is made. Clinicians should evaluate persons meeting the above description and, if indicated, admit them to the hospital. Close contacts and healthcare workers should seek medical care for symptoms of respiratory illness.

Clinicians evaluating suspected cases should use standard precautions (e.g., hand hygiene) together with airborne (e.g., N-95 respirator) and contact (e.g., gowns and gloves) precautions (see the Updated Interim Domestic Infection Control Guidance in the Health Care and Community Setting for Patients with Suspected SARS). Until the mode of transmission has been defined more precisely, eye protection also should be worn for all patient contact. As more clinical and epidemiologic information becomes available, interim recommendations will be updated.

Infection Control

Triage of Patients Who May Have Severe Acute Respiratory Syndrome: Interim Guidance for Screening in Ambulatory Care Settings
To facilitate identification of patients who may have SARS in ambulatory care settings, targeted screening questions concerning fever, respiratory symptoms, and recent travel should be included at triage or as soon as possible after patient arrival; the most recent case definition for SARS, accessible at http://www.cdc.gov/ncidod/sars/casedefinition.htm, should be used as a basis for such screening questions. Healthcare personnel who are the first points of contact should be trained for SARS screening; in the absence of systematic triage, providers caring for patients in ambulatory care settings should perform such screening before close contact.

A surgical mask should be placed on patients in whom SARS is suspected, and contact (e.g., gloves, gown, and eye protection) and airborne precautions (e.g., an isolation room with negative pressure relative to the surrounding area and use of an N-95 filtering disposable respirator, or respirators of equivalent filtering efficiency, for persons entering the room) should be applied where feasible. Where respirators are not available, healthcare personnel evaluating and caring for suspect SARS patients should wear a surgical mask. Additional guidance regarding SARS infection control in the ambulatory care setting is available at http://www.cdc.gov/ncidod/sars/infectioncontrol.htm.

Infection Control Precautions for Aerosol-Generating Procedures on Patients who have Suspected Severe Acute Respiratory Syndrome (SARS)

Multiple cases of suspected Severe Acute Respiratory Syndrome (SARS) have occurred in healthcare personnel who had cared for other patients with SARS. During the course of the investigation, CDC has received anecdotal reports that aerosol-generating procedures may have facilitated transmission of the etiologic agent of SARS in some cases. Procedures that induce coughing can increase the likelihood of droplet nuclei being expelled into the air. These potentially aerosol-generating procedures include aerosolized medication treatments (e.g., albuterol), diagnostic sputum induction, bronchoscopy, airway suctioning, and endotracheal intubation. For this reason, healthcare personnel should ensure that patients have been evaluated for SARS before initiation of aerosol-generating procedures. Evaluation for SARS should be based on the most recent case definition for SARS. Aerosol-inducing procedures should be performed on patients who may have SARS only when such procedures are deemed medically necessary. These procedures should be performed using airborne precautions as previously described for other infectious agents, such as Mycobacterium tuberculosis; Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities. In summary, healthcare personnel should apply standard, (e.g., hand hygiene), airborne (e.g., respiratory protective devices with a filter efficiency of greater than or equal to 95%), and contact (e.g., gloves, gown, and eyewear) precautions when aerosol-generating procedures are being performed on patients who may have SARS.

Other information on appropriate infection control precautions for patients with suspected SARS can be found in the Updated Interim Domestic Infection Control Guidance in the Health Care and Community Setting for Patients with Suspected SARS.

Treatment        
Because the etiology of these illnesses has not yet been determined, no specific treatment recommendations can be made at this time. Empiric therapy should include coverage for organisms associated with any community-acquired pneumonia of unclear etiology, including agents with activity against both typical and atypical respiratory pathogens (2). Treatment choices may be influenced by severity of the illness. Infectious disease consultation is recommended.

Clinicians evaluating suspected cases should use standard precautions (e.g., hand hygiene) together with airborne (e.g., N-95 respirator) and contact (e.g., gowns and gloves) precautions (see the Updated Interim Domestic Infection Control Guidance in the Health Care and Community Setting for Patients with Suspected SARS). Until the mode of transmission has been defined more precisely, eye protection also should be worn for all patient contact. As more clinical and epidemiologic information becomes available, interim recommendations will be updated.

World Health Organization  

See Latest Management of Severe Acute Respiratory Syndrome (SARS)  from W.H.O.

Management of Suspect and Probable SARS Cases    Revised 11 April 2003

  1. Hospitalize under isolation or cohort with other suspect or probable SARS cases (see Hospital Infection Control Guidance )
  2. Take samples (sputum, blood, sera, urine,) to exclude standard causes of pneumonia (including atypical causes); consider possibility of coinfection with SARS and take appropriate chest radiographs.
  3. Take samples to aid clinical diagnosis SARS including:
  4. White blood cell count, platelet count, creatine phosphokinase, liver function tests, urea and electrolytes, C reactive protein and paired sera. (Pair sera will be invaluable in the understanding of SARS even if the patient is later not considered a SARS case)
  5. At the time of admission the use of antibiotics for the treatment of community-acquired pneumonia with atypical cover is recommended
  6. Pay particular attention to therapies/interventions which may cause aerolization such as the use of nebulisers with a bronchodilator, chest physiotherapy, bronchoscopy, gastroscopy, any procedure/intervention which may disrupt the respiratory tract. Take the appropriate precautions (isolation facility, gloves, goggles, mask, gown, etc. ) if you feel that patients require the intervention/therapy.
  7. In SARS, numerous antibiotic therapies have been tried with no clear effect. Ribavirin with or without use of steroids has been used in an increasing number of patients. But, in the absence of clinical indicators, its effectiveness has not been proven. It has been proposed that a coordinated multicentred approach to establishing the effectiveness of ribavirin therapy and other proposed interventions be examined.

Definition of a SARS Contact

Management of Contacts of Probable SARS Cases

  1. Give information on clinical picture, transmission, etc. of SARS to the contact
  2. Place under active surveillance for 10 days and recommend voluntary home isolation
  3. Ensure contact is visited or telephoned daily by a member of the public health care team
  4. Record temperature daily
  5. If the contact develops disease symptoms, the contact should be investigated locally at an appropriate health care facility
  6. The most consistent first symptom that is likely to appear is fever

Management of Contacts of Suspect SARS Cases
As a minimum the following follow up is recommended:

  1. Give information on clinical picture, transmission etc of SARS to the contact
  2. Place under passive surveillance for 10 days
  3. If the contact develops any symptoms, the contact should self report via the telephone to the public health authority
  4. Contact is free to continue with usual activities
  5. The most consistent first symptom which is likely to appear is fever

Most national health authorities may wish to consider risk assessment on an individual basis and supplement the guidelines for the management of contacts of suspected SARS cases accordingly.

Removal from Follow up

Reporting

March 24, 2003, 2:00 PM EST

Healthcare providers and public health personnel should report cases of SARS (as described in the Interim Case Definition) to their state or local health departments.

For more information, contact either your state or local health department or the CDC Emergency Operations Center at 770-488-7100. Updated information will be made available on this website.

   

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Preliminary Clinical Description of Severe Acute Respiratory Syndrome

CDC

Severe acute respiratory syndrome (SARS) is a condition of corona virus etiology that has been described in patients in Asia, North America, and Europe. This report summarizes the clinical description of patients with SARS based on information collected since mid-February 2003 by the World Health Organization (WHO), Health Canada, and CDC in collaboration with health authorities and clinicians in Hong Kong, Taiwan, Bangkok, Singapore, the United Kingdom, Slovenia, Canada, and the United States. This information is preliminary and limited by the broad and necessarily nonspecific case definition.

As of March 21, 2003, the majority of patients identified as having SARS have been adults aged 25--70 years who were previously healthy. Few suspected cases of SARS have been reported among children aged <15 years.

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 begins generally with a prodrome of fever (>100.4°F [>38.0°C]). Fever often is high, sometimes is associated with chills and rigors, and might be accompanied by other symptoms, including headache, malaise, and myalgia. At the onset of illness, some persons have mild respiratory symptoms. Typically, rash and neurologic or gastrointestinal findings are absent; however, some patients have reported diarrhea during the febrile prodrome.

After 3-7 days, a lower respiratory phase begins with the onset of a dry, nonproductive cough or dyspnea, which might be accompanied by or progress to hypoxemia. In 10%--20% of cases, the respiratory illness is severe enough to require intubation and mechanical ventilation. The case-fatality rate among persons with illness meeting the current WHO case definition of SARS is approximately 3%.

Chest radiographs might be normal during the febrile prodrome and throughout the course of illness. However, in a substantial proportion of patients, the respiratory phase is characterized by early focal interstitial infiltrates progressing to more generalized, patchy, interstitial infiltrates. Some chest radiographs from patients in the late stages of SARS also have shown areas of consolidation.

Early in the course of disease, the absolute lymphocyte count is often decreased. Overall white blood cell counts have generally been normal or decreased. At the peak of the respiratory illness, approximately 50% of patients have leukopenia and thrombocytopenia or low-normal platelet counts (50,000--150,000/µL). Early in the respiratory phase, elevated creatine phosphokinase levels (as high as 3,000 IU/L) and hepatic transaminases (two to six times the upper limits of normal) have been noted. In the majority of patients, renal function has remained normal.

The severity of illness might be highly variable, ranging from mild illness to death. Although a few close contacts of patients with SARS have developed a similar illness, the majority have remained well. Some close contacts have reported a mild, febrile illness without respiratory signs or symptoms, suggesting the illness might not always progress to the respiratory phase.

Treatment regimens have included several antibiotics to presumptively treat known bacterial agents of atypical pneumonia. In several locations, therapy also has included antiviral agents such as oseltamivir or ribavirin. Steroids have also been administered orally or intravenously to patients in combination with ribavirin and other antimicrobials. At present, the most efficacious treatment regimen, if any, is unknown.

In the United States, clinicians who suspect cases of SARS are requested to report such cases to their state health departments. CDC requests that reports of suspected cases from state health departments, international airlines, cruise ships, or cargo carriers be directed to the SARS Investigative Team at the CDC Emergency Operations Center, telephone 770-488-7100. Outside the United States, clinicians who suspect cases of SARS are requested to report such cases to their local public health authorities. Additional information about SARS (e.g., infection control guidance and procedures for reporting suspected cases) is available at http://www.cdc.gov/ncidod/sars. Global case counts are available at http://www.who.int.

   

05012003