Severe Acute
Respiratory Syndrome (SARS)
Interim Information
and Recommendations for Health Care Providers
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 leucopenia. 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:
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
Epidemiology 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
HICPAC Isolation
Precautions
There are two tiers of HICPAC isolation precautions. In the first, and
most important tier, are those precautions designed for the care of all
patients in hospitals, regardless of their diagnosis or presumed
infection status. Implementation of these "Standard Precautions" is the
primary strategy for successful nosocomial infection control. In the
second tier are precautions designed only for the care of specified
patients. These additional "Transmission-Based Precautions" are for
patients known or suspected to be infected by epidemiologically
important pathogens spread by airborne or droplet transmission or by
contact with dry skin or contaminated surfaces.
Standard Precautions
Standard Precautions synthesize the major features of UP (Blood and Body
Fluid Precautions) (27,28) (designed to reduce the risk of transmission
of bloodborne pathogens) and BSI (29,30) (designed to reduce the risk of
transmission of pathogens from moist body substances) and applies them
to all patients receiving care in hospitals, regardless of their
diagnosis or presumed infection status. Standard Precautions apply to 1)
blood; 2) all body fluids, secretions, and excretions except sweat,
regardless of whether or not they contain visible blood; 3) nonintact
skin; and 4) mucous membranes. Standard Precautions are designed to
reduce the risk of transmission of microorganisms from both recognized
and unrecognized sources of infection in hospitals.
Transmission-Based Precautions
Transmission-Based Precautions are designed for patients documented or
suspected to be infected with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard
Precautions are needed to interrupt transmission in hospitals. There are
three types of Transmission-Based Precautions: Airborne Precautions,
Droplet Precautions, and Contact Precautions. They may be combined for
diseases that have multiple routes of transmission. When used either
singularly or in combination, they are to be used in addition to
Standard Precautions.
Airborne Precautions
are designed to reduce the risk of airborne transmission of infectious
agents. Airborne transmission occurs by dissemination of either airborne
droplet nuclei (small-particle residue [5 µm or smaller in size] of
evaporated droplets that may remain suspended in the air for long
periods of time) or dust particles containing the infectious agent.
Microorganisms carried in this manner can be dispersed widely by air
currents and may become inhaled by or deposited on a susceptible host
within the same room or over a longer distance from the source patient,
depending on environmental factors; therefore, special air handling and
ventilation are required to prevent airborne transmission. Airborne
Precautions apply to patients known or suspected to be infected with
epidemiologically important pathogens that can be transmitted by the
airborne route.
Droplet Precautions
are designed to reduce the risk of droplet transmission of infectious
agents. Droplet transmission involves contact of the conjunctivae or the
mucous membranes of the nose or mouth of a susceptible person with
large-particle droplets (larger than 5 µm in size) containing
microorganisms generated from a person who has a clinical disease or who
is a carrier of the microorganism. Droplets are generated from the
source person primarily during coughing, sneezing, or talking and during
the performance of certain procedures such as suctioning and
bronchoscopy. Transmission via large-particle droplets requires close
contact between source and recipient persons, because droplets do not
remain suspended in the air and generally travel only short distances,
usually 3 ft or less, through the air. Because droplets do not remain
suspended in the air, special air handling and ventilation are not
required to prevent droplet transmission. Droplet Precautions apply to
any patient known or suspected to be infected with epidemiologically
important pathogens that can be transmitted by infectious droplets.
Contact Precautions
are designed to reduce the risk of transmission of epidemiologically
important microorganisms by direct or indirect contact. Direct-contact
transmission involves skin-to-skin contact and physical transfer of
microorganisms to a susceptible host from an infected or colonized
person, such as occurs when personnel turn patients, bathe patients, or
perform other patient-care activities that require physical contact.
Direct-contact transmission also can occur between two patients (e.g.,
by hand contact), with one serving as the source of infectious
microorganisms and the other as a susceptible host. Indirect-contact
transmission involves contact of a susceptible host with a contaminated
intermediate object, usually inanimate, in the patient's environment.
Contact Precautions apply to specified patients known or suspected to be
infected or colonized (presence of microorganism in or on patient but
without clinical signs and symptoms of infection) with epidemiologically
important microorganisms than can be transmitted by direct or indirect
contact.
