SARS Health Alert Update

Missouri Department of Health & Senior Services
APRIL 3, 2003

FROM: RICHARD C. DUNN
DIRECTOR

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Contents
	Description
	Etiology
	Transmission
	Incubation Period
	Preliminary Clinical Description of SARS
	Specimen Collection for Potential Cases of SARS
	Treatment
	Clinical Consultation
	Infection Control Recommendations for Health Care and Community Settings
	Inpatient setting
	Precautions for aerosol-generating procedures on suspected SARS patients
	Management of exposures to SARS in a healthcare facility
	Biosafety guidelines for handling and processing SARS laboratory specimens
	Outpatient settings
	Households or residential settings
	Safe handling of human remains of SARS patients
	Advice for Travelers about SARS
	More Information

New Information Is Indicated in GREEN

DESCRIPTION
Severe Acute Respiratory Syndrome (SARS) is a communicable respiratory illness of unknown etiology that has recently been reported in a number of countries, particularly in parts of Asia. The main signs/symptoms of SARS include fever >38° C (100.4° F) and cough, shortness of breath, or difficulty breathing. In some affected persons, the illness can be very severe, and can result in death.

As of April 2, 2003, the cumulative number of reported SARS cases worldwide was 2,223 (including 78 deaths). Eighty-five suspect cases are from the United States (including 2 from Missouri). Other possible cases are under investigation, and the numbers of reported cases will continue to increase. Updated reports on the numbers of SARS cases, and the countries from which they have been reported, are available on the World Health Organization's (WHO's) SARS web site at http://www.who.int/csr/sars/en/.) Updated reports on U.S. cases are available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/od/oc/media/sars.htm. Note: because of the nonspecific case definition for SARS (see below), all reported cases might not represent a single clinical entity. Confirmation of the etiology and development of a diagnostic test will be of significant benefit in gaining a more precise understanding of the epidemiology of the disease.

The case definition for suspected SARS is subject to change, particularly concerning travel history as transmission is reported in other geographic areas; the current interim case definition is the following:

The previous CDC SARS case definition (published March 22, 2003) has been updated as follows:

• Areas with documented or suspected community transmission of SARS have been expanded to include all of mainland China in addition to areas previously listed.

Suspected Case:
Respiratory illness of unknown etiology with onset since February 1, 2003, and the following criteria:

• 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.

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ETIOLOGY
The agent responsible for SARS has not been confirmed, but laboratory data indicate that a metapneumovirus or a coronavirus are possible etiologic agents. CDC has identified a previously unrecognized coronavirus in patients with suspected or probable SARS. Sequence analysis suggests that this new agent is distinct from other known coronaviruses. Other laboratories outside the U.S., which are collaborating in the SARS investigation, have found similar results and also have isolated a different virus, human metapneumovirus, from some patients with suspected SARS. At the present time, information is insufficient to determine what roles these two viruses might play in the etiology of SARS.

TRANSMISSION
The majority of SARS cases are being seen in persons who were household contacts of a SARS case, or who were healthcare workers providing care to patients with SARS. 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). Transmission in hospitals and households is continuing to occur. In addition, reports have been received of possible transmission on ships and planes and in offices.

Although the mechanism of SARS transmission remains unclear, on the basis of the reported exposures for the majority of cases (i.e., household contacts and HCWs), droplet and contact transmission appear to be the predominant modes. The cases in a hotel cluster and certain hospital clusters involving seriously ill patients suggest airborne or fomite transmission. Therefore, infection-control recommendations should include precautions to prevent airborne, droplet, and contact transmission. With the introduction of these control measures, decreases in the reported incidence of SARS have been reported in Hong Kong.

In the U.S., efforts to prevent further transmission of the etiologic agent of SARS have been focused on rapid identification and early isolation of symptomatic persons whose illnesses meet the case definition.

(As mentioned in the preceding section, a previously unrecognized coronavirus is a possible etiologic agent for SARS, although this has not been confirmed. It is noted that coronaviruses are able to survive on environmental surfaces for up to 3 hours, and might be transmitted person-to-person by droplets, hand contamination, fomites, and small particle aerosols.)

INCUBATION PERIOD
The incubation period for SARS is typically 2-7 days; however, isolated reports have suggested an incubation period as long as 10 days.

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PRELIMINARY CLINICAL DESCRIPTION OF SARS

This section summarizes the clinical description of patients with SARS based on information collected since mid-February 2003. 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.

Clinicians should carefully evaluate persons suspected of having SARS and, if indicated, admit them to the hospital. Close contacts and healthcare workers should seek medical care for symptoms of respiratory illness.

Clinical consultation with CDC physicians on the evaluation of patients who are suspected of having SARS is available (see the section entitled "Clinical Consultation" below).

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 section below entitled "Infection Control Recommendations for Health Care and Community Settings"). 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.

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SPECIMEN COLLECTION FOR POTENTIAL CASES OF SARS
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. In addition, CDC has issued the following specific specimen collection recommendations for potential cases of SARS:

1. UPPER RESPIRATORY TRACT
   1. Nasopharyngeal wash/aspirate: Collect 1-2 ml into sterile vial.
      
   2. Nasopharyngeal/oropharyngeal swabs: Collect one NP and one OP swabs; use Dacron swabs with a non-wooden shaft.
      
      Place one NP swab and one OP swab into the same sterile vial containing 2 ml of viral transport media.
      
      
2. LOWER RESPIRATORY TRACT
   Broncheoalveolar lavage (BAL), tracheal aspirate, or pleural tap: Half of specimen centrifuged with cell pellet fixed in formalin. Remaining unspun specimen collected into sterile vials. If the patient is intubated and it is clinically indicated, consider a transbronchial, fine needle or open lung biopsy. For domestic transportation, store and ship on wet ice.
   
   
3. BLOOD COMPONENTS
   
   1. White Blood Cells: If available collect 8 ml whole blood in a CPT tube (Becton Dickinson), centrifuge 1500 RCF. For domestic transportation, ship on wet ice.
      
   2. Serum: Collect 5-10 ml of whole blood in serum separator tube. Allow blood to clot, centrifuge and aliquot resulting sera. If serum has already been frozen, ship on dry ice. If unfrozen, ship on wet ice.
      
   3. Whole blood: Collect 5-10 ml of whole blood in an EDTA (purple-top) tube. For domestic transportation, ship on wet ice.
      
      
4. TISSUE
   
   1. Fixed tissue: Formalin fixed or paraffin embedded tissue from all major organs (e.g. lung, trachea, heart, spleen, liver, brain, kidney, adrenals). Store and ship at room temperature. *DO NOT FREEZE FIXED TISSUES*
      
   2. Frozen tissue: Fresh frozen tissues from lung and upper airway (e.g. trachea, bronchus). Specimens should be collected aseptically via biopsy or at autopsy performed as soon as possible after death. Place each specimen in separate sterile containers containing small amounts of viral transport media or saline. Store and ship on dry ice.
      
      
5. URINE
   Optimal acute specimen is cell pellet from approximately 50 cc of first void morning urine specimen, re-suspended in 2-3 cc. viral transport medium, tissue culture medium or phosphate buffered saline. For domestic transportation, ship on wet ice.
   
   
6. STOOL
   Stool (10-50 cc) should be placed in a stool cup or urine container, securely capped, sealed with parafilm and bagged. For domestic transportation, ship on wet ice.
   
   
7. LABELING AND DOCUMENTATION
   
   1. Specimen labeling: Each specimen should be labeled with the patient ID number and date collected.
      
   2. Accompanying documentation: The package should include a linelist for all specimens including patient name and ID number, date collected, samples collected, clinical contact name and phone number, and submitter contact name and phone number OR a completed specimen submission form (http://www.cdc.gov/ncidod/dvrd/spb/pdf/specsubmission.pdf).
      
      
8. SHIPPING
   
   1. For US domestic transportation, store and ship all non-tissue specimens on wet ice. Frozen tissues should be sent on dry ice.
      
   2. For international transportation, store and ship all non-tissue specimens on dry ice. Fixed tissues should not be frozen.
      
   3. Package according to IATA Regulations as described in the Consignment of Diagnostic Specimens 2003 available at IATA: Dangerous Goods website (http://www.iata.org/dangerousgoods/index).
      
   4. For domestic U.S. shipments use Delta DASH for same day delivery (1-800-638-7333) or FedEx for next day delivery (1-800-463-3339). International shipments should be done using the best carrier available.
      
   5. Label all packages: "Diagnostic Specimens. UN 3373. Packed in compliance with IATA packing instructions 650".
      
   6. Address the packages to:
      SARS Investigation
      Centers for Disease Control and Prevention, Viral Special Pathogens Branch
      1600 Clifton Rd NE (MS G-14), Bldg. 15, Rm. B105
      Atlanta, GA 30333
      Phone: (770)-488-7100

Clinicians should save any available clinical specimens (respiratory, blood, serum, tissue, etc.) for additional testing until a specific diagnosis is made.

If a patient is suspected to have SARS, the Missouri Department of Health and Senior Services should be immediately notified at 1-800-392-0272 (24 hours a day/7 days a week). DHSS and the Missouri State Public Health Laboratory will work with CDC to provide consultation on laboratory specimen collection and coordinate the transportation of appropriate specimens to CDC for further testing.

More detailed information on specimen collection, handling, and submission, as well as a specimen submission form, is available on CDC's SARS web site (http://www.cdc.gov/ncidod/sars/specimens.htm).

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TREATMENT
CDC has stated that, because the etiology of SARS 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.* Treatment choices may be influenced by the severity of the illness. Infectious disease consultation is recommended. Clinical consultation with CDC physicians on treatment of suspected/confirmed cases is also available and is strongly encouraged (see the next section entitled "Clinical Consultation").

As stated above, treatment regimens that have been utilized to date 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. CDC emphasizes that, at present, the most efficacious treatment regimen, if any, is unknown.

*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

CLINICAL CONSULTATION
Clinical consultation on suspected/confirmed SARS cases is available from CDC's SARS Clinical Management Team at 770-488-7100.

INFECTION CONTROL RECOMMENDATIONS FOR HEALTH CARE AND COMMUNITY SETTINGS
CDC has issued the following interim guidance concerning infection control precautions in health care and community settings. To minimize the potential for transmission, these precautions are recommended, as feasible given available resources, until the causative agent is isolated or the epidemiology of illness transmission is better understood. Health care personnel should apply these precautions for any contact with patients with suspected SARS.

For all contact with suspect SARS patients, careful hand hygiene is urged, including hand washing with soap and water; if hands are not visibly soiled, alcohol-based handrubs may be used as an alternative to hand washing.

Access http://www.cdc.gov/handhygiene for more information on hand hygiene.

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Infection control recommendations for the inpatient setting:
If a suspect SARS patient is admitted to the hospital, infection control personnel should be notified immediately. Infection control measures for inpatients (http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm) should include:

• Standard precautions (e.g., hand hygiene); in addition to routine standard precautions, health care personnel should wear eye protection for all patient contact.
  
• Contact precautions (e.g., use of gown and gloves for contact with the patient or their environment)
  
• Airborne precautions (e.g., an isolation room with negative pressure relative to the surrounding area and use of an N-95 filtering disposable respirator for persons entering the room)

If airborne precautions cannot be fully implemented, patients should be placed in a private room, and all persons entering the room should wear N-95 respirators. Where possible, a qualitative fit test should be conducted for N-95 respirators; detailed information on fit testing can be accessed at http://www.osha.gov/SLTC/etools/respiratory/oshafiles/fittesting1.html. If N-95 respirators are not available for health care personnel, then surgical masks should be worn. Regardless of the availability of facilities for airborne precautions, standard and contact precautions should be implemented for all suspected SARS patients.

Infection control precautions for aerosol-generating procedures on suspected SARS patients
Multiple cases of suspected 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 (see the section entitled "Description" above). 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" (http://www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htm).

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.

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Interim guidance for the management of exposures to SARS in a healthcare facility

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.
   
   
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 given below in the section entitled "Infection control recommendations for the home or residential setting."
   
   
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.

(Note that these recommendations concerning management of exposed healthcare workers could be adapted and applied to other settings, including schools and other institutional settings.)

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Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with SARS
Effective and timely communication between clinical and laboratory staff is essential in minimizing the risk incurred in handling specimens from patients for whom SARS is suspected. Specimens from patients with suspected SARS should be labeled accordingly and the laboratory should be alerted to insure proper specimen handling. Listed below are interim biosafety guidelines for handling these specimens:

1. Blood Specimens for Routine Serology, Chemistry and Hematology:
   These specimens may be handled using Standard Precautions (previously Universal Precautions). Laboratory workers should wear protective equipment, including disposable gloves, laboratory coats, eye protection and a surgical mask, or face shield to provide a barrier to mucosal surface exposure. Centrifugation should be carried out using sealed centrifuge cups or rotors that are loaded and unloaded in a biological safety cabinet.
   
   
2. Specimens for Microbiological Analysis
   
   1. The following activities may be performed in Biosafety Level (BSL) 2 facilities using BSL-2 practices as described in the CDC/NIH Biosafety in Microbiological and Biomedical Laboratories manual (http://www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4toc.htm):
      
      1. Pathologic examination and processing of formalin-fixed or otherwise inactivated tissues.
         
      2. Molecular analysis of extracted nucleic acid preparations.
         
      3. Electron microscopic studies with glutaraldehyde-fixed grids.
         
      4. Routine examination of bacterial and mycotic cultures.
         
      5. Routine staining and microscopic analysis of fixed smears.
      6. Final packaging of specimens for transport to diagnostic laboratories for additional testing. Specimens should already be in a sealed, decontaminated primary container.
         
         
   2. Activities involving manipulation of untreated specimens may be performed in BSL-2 facilities, but with more stringent BSL-3 work practices. All specimen manipulations should be carried out in a certified biological safety cabinet. Laboratory workers should wear protective equipment, including disposable gloves, solid front gowns with cuffed sleeves, eye protection and respiratory protection. Acceptable methods of respiratory protection include a NIOSH approved filter respirator (N-95 or higher); or powered air-purifying respirators (PAPRs). equipped with high efficiency particulate air (HEPA) filters. Personnel who cannot wear fitted respirators because of facial hair or other fit-limitations should wear loose fitting hooded or helmeted PAPRs. Centrifugation should be carried out using sealed centrifuge cups or rotors that are loaded and unloaded in a biological safety cabinet. These activities include:
      
      1. Aliquoting and/or diluting specimens
         
      2. Inoculation of bacterial or mycological culture media.
         
      3. Performing diagnostic tests that don't involve propagation of viral agents in vitro or in vivo.
         
      4. Nucleic acid extraction procedures involving untreated specimens
      5. Preparation and chemical- or heat-fixing of smears for microscopic analysis.
         
         
   3. The following activities require BSL-3 facilities and BSL-3 work practices:
      
      1. Viral cell culture
         
      2. Initial characterization of viral agents recovered in cultures of SARS specimens.
         
         
   4. The following activities require Animal BSL-3 facilities and Animal BSL-3 work practices:
      
      1. Inoculation of animals for potential recovery of the agent from SARS samples.
         
      2. Protocols involving animal inoculation for characterization of putative SARS agents.
         
         Packaging, shipping and transport of specimens from suspect and probable SARS cases must follow the current edition of the International Air Transport Association (IATA) Dangerous Goods Regulations (http://www.iata.org/dangerousgoods/index) and US DOT 49 CFR Parts 171-180 (http://hazmat.dot.gov/rules.htm). Step-by-step instructions on appropriate packaging and labelling can be viewed at http://www.cdc.gov/ncidod/sars/pdf/packingspecimens-sars.pdf.

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Infection control recommendations for the outpatient setting:
Any person who presents to a medical care setting with a febrile respiratory illness should, upon arrival and before any close contact with others, be initially evaluated to see if he/she might, based on signs/symptoms and recent travel history* or recent contact with a potential SARS case, have SARS. Ideally, healthcare personnel who are the first point of contact should be trained for SARS screening. Targeted screening questions concerning fever, respiratory symptoms, and recent travel should be included.

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.

CDC stresses that all health care personnel should wear N-95 respirators while taking care of patients with suspected SARS. Precautions should be used when evaluating or transporting patients (e.g., emergency medical technicians), or in any ambulatory healthcare setting (e.g., ED or clinic personnel). If N-95 respirators are not available, surgical masks should be worn by personnel.

*Regarding recent travel, of concern at the present time would be an individual who had, within the preceding 10 days, been in Hong Kong Special Administrative Region or Guangdong Province, Peoples' Republic of China; Hanoi, Vietnam; or Singapore. Areas of concern with regard to recent travel may change over time; the most current information is found at http://www.cdc.gov/ncidod/sars.

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Infection control measures for patients with suspected SARS in households or residential settings
Patients with SARS pose a risk of transmission to close household contacts and health care personnel in close contact. The duration of time before or after onset of symptoms during which a patient with SARS can transmit the disease to others is unknown. The following infection control measures are recommended for patients with suspected SARS in households or residential settings. These recommendations are based on the experience in the United States to date and may be revised as more information becomes available.

• SARS patients should limit interactions outside the home and should not go to work, school, out-of-home child care, or other public areas until ten days after resolution of fever and respiratory symptoms. During this time, infection control precautions should be used, as described below, to minimize the potential for transmission.
  
  
• All members of a household with a SARS patient should carefully follow recommendations for hand hygiene (e.g., frequent hand washing or use of alcohol-based hand rubs), particularly after contact with body fluids (e.g., respiratory secretions, urine, or feces). See the "Guideline for Hand Hygiene in Healthcare Settings (2002)" (http://www.cdc.gov/handhygiene/) for more details on hand hygiene.
  
  
• Use of disposable gloves should be considered for any direct contact with body fluids of a SARS patient. However, gloves are not intended to replace proper hand hygiene. Immediately after activities involving contact with body fluids, gloves should be removed and discarded and hands should be cleaned. Gloves must never be washed or reused.
  
  
• Each patient with SARS should be advised to cover his or her mouth and nose with a facial tissue when coughing or sneezing. If possible, a SARS patient should wear a surgical mask during close contact with uninfected persons to prevent spread of infectious droplets. When a SARS patient is unable to wear a surgical mask, household members should wear surgical masks when in close contact with the patient.
  
  
• Sharing of eating utensils, towels, and bedding between SARS patients and others should be avoided, although such items can be used by others after routine cleaning (e.g., washing with soap and hot water). Environmental surfaces soiled by body fluids should be cleaned with a household disinfectant according to manufacturer's instructions; gloves should be worn during this activity.
  
  
• Household waste soiled with body fluids of SARS patients, including facial tissues and surgical masks, may be discarded as normal waste.
  
  
• Household members or other close contacts of SARS patients who develop fever or respiratory symptoms should seek healthcare evaluation. When possible, in advance of the evaluation, healthcare providers should be informed that the individual is a close contact of a SARS patient. Household members or other close contacts with symptoms of SARS should follow the same precautions recommended for SARS patients.
  
  
• At this time, in the absence of fever or respiratory symptoms, household members or other close contacts of SARS patients need not limit their activities outside the home.
  

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Safe handling of human remains of SARS patients: interim domestic guidance
All postmortem procedures require adherence to standard precautions with use of appropriate personal protective equipment (PPE) and facilities with appropriate safety features. Mechanical devices used during autopsies can efficiently generate fine aerosols that may contain infectious organisms. Thus, PPE should include both protective garments and respiratory protection as outlined below.

Personal protective equipment

For autopsies and postmortem assessment of SARS cases, PPE should include:

• Protective garments: surgical scrub suit, surgical cap, impervious gown or apron with full sleeve coverage, eye protection (e.g., goggles or face shield), shoe covers and double surgical gloves with an interposed layer of cut-proof synthetic mesh gloves.
  
  
• Respiratory protection: N-95 or N-100 respirators; or powered air-purifying respirators (PAPR) equipped with a high efficiency particulate air (HEPA) filter. PAPR is recommended for any procedures that result in mechanical generation of aerosols, e.g., use of oscillating saws. Autopsy personnel who cannot wear N-95 respirators because of facial hair or other fit-limitations should wear PAPR.

Autopsy procedures

For autopsies and postmortem assessment of SARS cases, safety procedures should include:

• Prevention of percutaneous injury: including never recapping, bending or cutting needles, and ensuring that appropriate sharps containers are available.
  
  
• Handling of protective equipment: protective outer garments must be removed when leaving the immediate autopsy area and discarded in appropriate laundry or waste receptacles, either in an antechamber to the autopsy suite or immediately inside the entrance if an antechamber is not available. Hands should be washed upon glove removal.

Engineering strategies and facility design

• Air handling systems: autopsy suites must have adequate air-exchanges per hour and correct directionality and exhaust of airflow. Autopsy suites should have a minimum of 12 air-exchanges per hour and should be at a negative pressure relative to adjacent passageways and office spaces. Air should not be returned to the building interior, but should be exhausted outdoors, away from areas of human traffic or gathering spaces (e.g., off the roof) and away from other air intake systems. For autopsies, local airflow control (i.e., laminar flow systems), can be used to direct aerosols away from personnel; however, this safety feature does not remove the need for appropriate personal protective equipment.
  
  
• Containment devices: biosafety cabinets should be available for handling and examination of smaller specimens. Oscillating saws are available with vacuum shrouds to reduce the amount of particulate and droplet aerosols generated. These devices should be used whenever possible to decrease the risk of occupational infection.

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ADVICE FOR TRAVELERS ABOUT SARS

Background

• Severe acute respiratory syndrome (SARS) is a new respiratory disease linked to travel to mainland China, Hong Kong, Singapore, and Hanoi (Vietnam).
  
  
• In general, SARS starts with a fever higher than 100.4°F [>38.0°C]. Other symptoms may include headache, an overall feeling of discomfort, and body aches. Some people also feel short of breath. After 3 to 7 days, the person may get a dry cough and have trouble breathing.
  
  
• Public health experts think that SARS is spread by close contact between people. For example, the disease can spread from someone who is sick with SARS to healthcare workers who have taken care of them or to family members. It is most likely spread when someone sick with SARS coughs droplets into the air and someone else breathes them in. SARS does not seem to spread easily by casual contact in large groups of people.
  
  
• The World Health Organization and the Centers for Disease Control and Prevention (CDC) are still looking into the causes of SARS.
  
  
• For more on SARS, go to www.cdc.gov/ncidod/sars/index.htm.
  
  
• New facts about SARS come up daily. Get the latest on how many people have SARS and what countries are touched, at www.cdc.gov/od/oc/media/sars.htm and www.who.int/csr/sarscountry/en/.
  

Before you travel

• Don't go to mainland China, Hong Kong, Singapore, and Hanoi, unless you really have to. You can still go to Canada. SARS doesn't seem to spread there right now.
  
  
• Be sure you are current on all your shots. See your healthcare provider at least 4-6 weeks before travel to get the latest shots and facts you need. For more on CDC health advice for travel abroad, see www.cdc.gov/travel.
  
  
• Check your health insurance. You may want to get more coverage for medical evacuation in case you get sick abroad. For more on this, go to www.travel.state.gov/medical.html.
  
  
• Ask the U.S. Department of State (DOS) about healthcare services in the country you're going to. DOS has a list of foreign healthcare providers and healthcare facilities at www.travel.state.gov/acs.html#medical.
  
  
• If you get sick while traveling in an area affected by SARS
  
  • See a healthcare provider and say that you're worried about being exposed to SARS.
    
  • Don't travel while sick. Limit your contact with others as much as you can to help prevent the spread of any contagious disease you may have.
    
  • If you don't know of any provider in the foreign country, call the U.S. embassy or consulate to get the name of a provider.
    
    
• As with all contagious diseases, the best way not to get sick is to wash your hands often with soap and water. If you don't have soap and water, use alcohol-based hand rubs.

When you come back home from areas affected by SARS

• If you were sick on your trip or return home sick, see your healthcare provider right away. Mention your symptoms and the countries you went to. You may be asked to fill out a form about your disease and give your name and address to public health authorities.
  
  
• If you leave an area affected by SARS, a screener may ask you about your health before you board the plane.
  
  
• If you come back from areas affected by SARS, you will get a travel alert card when you land. If you are not sick now and were not sick while abroad but may have been in touch with someone with SARS, check your health for the next 10 days.

For additional information about travel advisories, check www.cdc.gov/travel, which will be updated as necessary.

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MORE INFORMATION

Anyone having questions about SARS can contact DHSS at 1-800-392-0272.

CDC's SARS web site (contains the most recent information and recommendations for medical professionals and the public) http://www.cdc.gov/ncidod/sars/

WHO's SARS web site http://www.who.int/csr/sars/en/

Download This Document in PDF Format

Please contact the Missouri Department of Health and Senior Services (DHSS) if you have any questions at 1-800-392-0272.

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