|
Clallam County Department of Health and Human Services
Health Alert
Surveillance for Severe Acute Respiratory Syndrome (SARS) in Patients with Recent Travel to Asia or Their Close Contacts
March 17, 2003
The Clallam County Department of Health & Human Services, Washington State Department of Health, the CDC and the World Health Organization (WHO) are requesting heightened surveillance for persons with acute respiratory illnesses that fit the CDC case definition of Severe Acute Respiratory Syndrome (SARS).
The CDC Case Definition Of SARS
A history of illness onset since February 1, 2003 that includes:
AND
>1 respiratory sign or symptom, including cough, shortness of breath, difficulty breathing, hypoxia, or radiographic findings of pneumonia or respiratory distress syndrome
travel to areas reporting cases of SARS (including Hong Kong, Guangdong Province in the People's Republic of China, and Hanoi, Viet Nam) within 7 days prior to illness onset OR close contact1 with a person who has been diagnosed with SARS.
Patients with recent travel to Asia who develop fever and acute respiratory disease syndromes should be rapidly isolated in an airborne infection isolation room with airborne and contact precautions.
Immediately report all patients who meet the CDC case definition of SARS to the Clallam County Health Department at 360-417-2439 or after hours to Thomas Locke MD at 360-582-8353 or 360-808-3333.
Background of Current Investigations
Since mid-February, WHO has been investigating outbreaks of severe acute respiratory disease in Viet Nam, Hong Kong, and Guangdong province in China, as well as recent reports of suspected cases from other parts of Asia, including Singapore, Thailand, Indonesia, the Philippines and Taiwan. Eight cases have also been reported in Canada: six in a family in Toronto, Ontario (two family members have died, including the index case), and two in a family in Vancouver, British Columbia (one family member remains hospitalized). Illness in both families occurred following the return of a family member from Hong Kong.
To date, WHO reports >150 suspected cases; it is unclear if these outbreaks are related and the etiology of this disease is unknown. The outbreaks appear to primarily affect family members and health care workers who have had direct contact with patients.
In the United States, a case has been reported in a traveler from Singapore who visited New York City. The patient is a physician; before leaving for the U. S. on March 11th, he had cared for patients with an unexplained respiratory illness in Singapore, where 16 cases of SARS have been reported. He developed a febrile illness with myalgias and a maculopapular rash in Singapore. He was evaluated as an outpatient in New York City, and had a left lower lobe pneumonia on chest x-ray, with normal peripheral blood counts. He was treated with oral antibiotics, and left New York City on March 14th. En route back to Singapore, he was hospitalized in Frankfurt, Germany due to concern that his illness may be related to the Asian outbreaks. He is clinically stable and remains in isolation pending further evaluation. A family member traveling with the patient developed fever and myalgias and is in isolation pending further evaluation.
Clinical Presentation
Early symptoms include a flu-like illness with high fever, followed by myalgias, headache, dry cough, sore throat and respiratory distress. Laboratory findings may include thrombocytopenia and leukopenia. Some patients develop hypoxia and pneumonia (often interstitial) which may progress to respiratory failure requiring mechanical ventilation. Some patients have died, others remain critically ill, and some are recovering.
The incubation period may be 1-2 days or as long as 7 (mean of 4 days). Transmission appears to be via respiratory droplets, and most secondary cases have been among healthcare workers or family members who have had direct contact with patients. Airborne or contact transmission has not been ruled out.
Isolation Precautions for Any Suspected or Probable Cases:
Patients seen in an emergency department or clinic should have a surgical mask placed on them immediately and should be placed in an airborne infection isolation room, with negative pressure airflow. Infection control and public health personnel should be immediately notified regarding the suspected case. Consultations should be requested from an infectious disease specialist.
As secondary spread to healthcare workers has occurred in Asia, all suspected case-patients should be isolated in an airborne infection isolation room. All staff and visitors entering the room should adhere to both airborne and contact precautions.
Signs noting the need for airborne and contact precautions should be displayed outside patients' rooms. Staff and visitors entering the room should adhere to contact, airborne and standard precautions, and don contact and airborne personal protection equipment before entering a patient's room (i.e., disposable gloves and gowns, eye protection and an N-95 or higher respirator). Precautions must include careful attention to hand hygiene.
These precautions should be maintained until the etiology and route of transmission for this illness are better understood.
Laboratory Testing:
Initial diagnostic testing should include chest radiograph, pulse oximetry, complete blood counts, blood cultures, sputum Gram's stain and bacterial culture, and nasopharyngeal or throat swabs, sputum, or other respiratory specimens to test for viral respiratory pathogens (including influenza A and B and respiratory syncytial virus). If bronchoscopy, transtracheal and/or lung biopsy are performed, both fresh, frozen tissue and formalinized specimens should be obtained for testing at CDC and other reference laboratories. Fresh, frozen and formalinized tissue should also be obtained if an autopsy is performed in fatal cases.
Clinicians should save any available clinical specimens (respiratory, blood and serum) for additional testing until a specific diagnosis is made.
Your local health department or DOH will provide additional information on appropriate specimen collection at the time of consultation. We will also arrange rapid transport of these specimens to the DOH Public Health Laboratories for shipment to the CDC and other reference laboratories. Call Communicable Disease Epidemiology at (206) 361-2914, or (877) 539-4344.
Treatment:
Because the etiology of these illnesses is unknown, no specific treatment recommendations can be made at this time. Empiric therapy for community-acquired pneumonia of unclear etiology should be given, including agents with activity against both typical and atypical respiratory pathogens. Treatment choices may be influenced by severity of the illness and an infectious disease consultation is recommended.
Travel Advisories:
The CDC will be issuing health alerts to travelers returning from Asia. Any traveler to an area where SARS has been reported should be instructed to seek medical attention if they develop fever and respiratory symptoms.
There is presently no recommendation from the WHO for people to restrict travel to any destination. |
