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Clallam County Department of Health and Human Services

March 31, 2003

Clallam County Health & Human Services (CCHHS), Washington State Department of Health (DOH), the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) are requesting continued heightened surveillance for persons with acute respiratory illnesses that fit the CDC case definition of severe acute respiratory syndrome (SARS).  Contact Clallam County staff at (360) 417-2439 or 417-2542 for more information.

Excerpt of joint press release (Washington State Department of Health and Public Health - Seattle & King County), March 28, 2003.

Two suspected cases of Severe Acute Respiratory Syndrome (SARS) in Washington State

Two King County residents have been listed as the first suspected cases of severe acute respiratory syndrome (SARS) in Washington state. Both individuals were exposed outside of the United States, and there has been no evidence of transmission from these cases to other King County residents.

Public Health - Seattle & King County and the state Department of Health are closely monitoring the situation, and there is currently no cause for alarm in King County or Washington state.  SARS is a new disease that appears to have emerged from parts of Asia. The cause is unknown, but the Centers for Disease Control and Prevention and the World Health Organization say there is some evidence it may be a corona virus, the same family of viruses that cause the common cold. More information is available on the Washington State Department of Health SARS Health Alert Web page http://www.doh.wa.gov/sars.htm

CDC Case Definition for SARS  (updated 3/29/2003)

• Measured temperature > 100.4°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 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
  
  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.

Excerpt from CDC Health Advisory Network (HAN) Health Update, March 24, 2003.

Supplemental Information: Novel Coronavirus Linked to Severe Acute Respiratory Syndrome

CDC officials emphasized that the laboratory results announced today are preliminary and do not provide conclusive evidence that the new agent is the cause of SARS.   Several laboratories collaborating in the WHO-led investigation had previously reported the isolation of a different virus - human metapneumovirus - from patients with SARS.  There is insufficient information at this time to determine what role the new coronavirus or metapneumovirus has in the cause of SARS. 

SARS 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.

Diagnosis and 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.

Additional Information

Clallam County Health & Human Services: (360)417-2439 or 2542    http://www.clallam.net

CDC SARS Web page: http://www.cdc.gov/ncidod/sars/index.htm

Washington Dept. of Health SARS Health Alert Web page:   http://www.doh.wa.gov/sars.htm

Management of Exposures to SARS for Healthcare and Other Institutional Settings    (CDC interim guidelines, 3/27/2003)

Several healthcare workers have been reported to develop Severe Acute Respiratory Syndrome (SARS) after caring for patients with SARS. Although the infectivity and etiology of SARS are currently unknown, 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 (i.e., unprotected exposures). Personal protective equipment appropriate for standard, contact, and airborne precautions (e.g., hand hygiene, gown, gloves, and N95 respirator) in addition to eye protection, have been recommended for healthcare workers to prevent transmission of SARS in healthcare settings (see infection control web page  http://www.cdc.gov/ncidod/sars/ic.htm ).

1. 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 (see infection control web page  http://www.cdc.gov/ncidod/sars/ic.htm ).
2. Exclusion from duty is not recommended for an exposed healthcare worker if they do not have either fever or respiratory symptoms; however, the worker should report any unprotected exposure to SARS patients to the appropriate facility point of contact (e.g., infection control or occupational health) immediately.
3. Active surveillance for fever and respiratory symptoms (e.g., daily screening) should be conducted on healthcare workers with unprotected exposure, and the worker should be vigilant for onset of illness. Workers with unprotected exposure developing such symptoms should not report for duty, but should stay home and report symptoms to the appropriate facility point of contact immediately. Recommendations for appropriate infection control for SARS patients in the home or residential setting are available online http://www.cdc.gov/ncidod/sars/ic.htm.
4. Passive surveillance (e.g., review of occupational health or other sick leave records) should be conducted among all healthcare workers in a facility with a SARS patient, and all healthcare facility workers should be educated concerning the symptoms of SARS.
5. 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 healthcare facility as visitors and should be educated about this policy. A system for screening SARS close contacts who are visitors to the facility for fever or respiratory symptoms should be in place. Healthcare facilities should educate all visitors about use of infection control precautions when visiting SARS patients and their responsibility for adherence to them.

To date, all patients with SARS reported to CDC in the United States have been either persons with a history of foreign travel to countries with SARS transmission or close contacts (e.g., family members or healthcare workers) to other SARS cases. Transmission has not been reported at schools, other institutions, or public gatherings in the United States. However, these recommendations concerning management of exposed healthcare workers could be adapted and applied to other settings, including schools and other institutional settings, as deemed appropriate.