CDC HEALTH ADVISORY
MARCH 15, 2003

Following is information regarding the current WHO investigation of atypical pneumonia. Included are: a news release from the CDC, interim information and recommendations for health care providers, and text of a travelers' health alert card which will be distributed to targeted international travelers returning to the U.S.

CDC Issues Health Alert About Atypical Pneumonia

Atlanta: In response to reports of increasing numbers of cases of an atypical pneumonia that the World Health Organization (WHO) has called Severe Acute Respiratory Syndrome (SARS), the Centers for Disease Control and Prevention (CDC) today announced several steps to alert US health authorities at local and state levels.

CDC activated its emergency operations center on Friday, March 14, upon learning of several cases reported in Canada among travelers recently returned from Southeast Asia and their family members. The federal public health agency:

• Issued a health alert to hospitals and clinicians on Saturday, March 15.
  
• Briefed state health officials on Saturday, March 15.
  
• Is investigating illness among travelers who may have passed through the United States after having potential exposure to the virus.
  
• Is preparing health alert cards to give to travelers returning from Southeast Asia.
  
• Is preparing guidance to assist public health departments, health care facilities and clinicians in monitoring and identifying potential cases.
  
• Deployed eight CDC scientists to assist the WHO in the global investigation.
  
• Is analyzing specimens to identify a cause for the illness.
  

CDC has been working with the World Health Organization (WHO) since late February to investigate and confirm outbreaks of this severe form of pneumonia in Viet Nam, Hong Kong, and parts of China. No cases have been identified to date in the United States.

"The emergence of two clusters of this illness on the North American continent indicates the potential for travelers who have been in the affected areas of Southeast Asia to have been exposed to this serious syndrome," said Dr. Julie L. Gerberding, CDC Director. "The World Health Organization has been leading a global effort, in which CDC is participating, to understand the cause of this illness and how to prevent its spread. We do know that it may progress rapidly and can be fatal. Therefore, we are instituting measures aimed at identifying potential cases among travelers returning to the United States and protecting the people with whom they may come into contact."

The WHO issued a global alert about the outbreak on March 12, cautioning that the severe respiratory illness may spread to hospital staff. No link has been made between this illness and any known influenza, including the "bird flu" (A[H5N1]) outbreak reported in Hong Kong on February 19.

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Severe Acute Respiratory Syndrome (SARS)
Interim Information and Recommendations for Health Care Providers

3/15/2003

The Centers for Disease Control and Prevention (CDC) and the World Health Organization have received reports of patients with severe acute respiratory syndrome (SARS) from Canada, China, Hong Kong Special Administrative Region of China, Indonesia, Philippines, Singapore, Thailand, and Vietnam. The cause of these illnesses is unknown and is being investigated. Early manifestations in these patients have included influenza-like symptoms such as fever, myalgias, headache, sore throat, dry cough , shortness of breath, or difficulty breathing. In some cases these symptoms are followed by hypoxia, pneumonia, and occasionally acute respiratory distress requiring mechanical ventilation and death. Laboratory findings may include thrombocytopenia and leukopenia. Some close contacts, including healthcare workers, have developed similar illnesses. In response to these developments, CDC is initiating surveillance for cases of SARS among recent travelers or their close contacts.

Case Finding
Clinicians should be alert for persons with onset of illness after February 1, 2003 with:

• Fever (>38° C)
  

AND

• One or more signs or symptoms of respiratory illness including cough, shortness of breath, difficulty breathing, hypoxia, radiographic findings of pneumonia, or respiratory distress

AND
One or more of the following:

• History of travel to Hong Kong or Guangdong Province in People's Republic of China, or Hanoi, Vietnam, within seven days of symptom onset
  
• Close contact with persons with respiratory illness having the above travel history. Close contact includes having cared for, having lived with, or having had direct contact with respiratory secretions and body fluids of a person with SARS.
  

Diagnostic 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.

Infection Control
If the patient is admitted to the hospital, clinicians should notify infection control personnel immediately. Until the etiology and route of transmission are known, in addition to standard precautions(1), infection control measures for inpatients should include:

• Airborne precautions (including an isolation room with negative pressure relative to the surrounding area and use of an N-95 respirator for persons entering the room)
  
• Contact precautions (including use of gown and gloves for contact with the patient or their environment)
  

Standard precautions routinely include careful attention to hand hygiene. When caring for patients with SARS, clinicians should wear eye protection for all patient contact.

To minimize the potential of transmission outside the hospital, case patients as described above should limit interactions outside the home until the epidemiology of illness transmission is better understood. Placing a surgical mask on case patients in ambulatory healthcare settings, during transport, and during contact with others at home is prudent.

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.

Reporting
Healthcare providers and public health personnel should report cases of SARS as described above to their state or local health departments.

For more information contact your state or local health department or the CDC Emergency Operations Center 770-488-7100. Updated information will be available at http://www.cdc.gov

References

1. Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:53-80, and Am J Infect Control 1996;24:24-52. http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm

2. Bartlett JG, Dowell SF, Mandell LA, File Jr, TM, Musher DM, and Fine MJ. Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults. Clin Infect Dis 2000;31:347-82. http://www.journals.uchicago.edu/CID/journal/issues/v31n2/000441/000441.web.pdf

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Text of a travelers' health alert card:

HEALTH ALERT NOTICE
FOR INTERNATIONAL TRAVELERS ARRIVING IN OR RETURNING TO THE USA FROM HONG KONG AND GUANGDONG PROVINCE, PEOPLE'S REPUBLIC OF CHINA, AND HANOI, VIETNAM

TO THE TRAVELER: During your recent travel, you may have been exposed to cases of severe acute respiratory disease syndrome. You should monitor your health for at least 7 days. If you become ill with fever accompanied by cough or difficulty in breathing, you should consult a physician. To help your physician make a diagnosis, tell him or her about your recent travel to these regions and whether you were in contact with someone who had these symptoms. Please save this card and give it to your physician if you become ill.

TO THE PHYSICIAN: The patient presenting this card may have recently traveled to Hong Kong or Guangdong Province in the People's Republic of China or Hanoi, Vietnam, where cases of atypical pneumonia have been identified. If you suspect atypical pneumonia (also being called severe acute respiratory disease syndrome [SARS]), please contact your city, county, or state health officer (see http://www.cdc.gov or call the CDC Emergency Operations Center 770-488-7100).

For public inquiries, call Centers for Disease Control and Prevention (CDC) hotline: English 888-246-2675, Español 888-246-2857, TTY 866-874-2646.

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