PENNSYLVANIA DEPARTMENT OF HEALTH HEALTH ALERT #43 Date: March 27, 2003 Subject: SEVERE ACUTE RESPIRATORY SYNDROME (SARS) To: Health Alert Network From: Robert S. Muscalus, DO, Acting Secretary of Health This transmission is a "Health Alert", conveys the highest level of importance; warrants immediate action or attention. HOSPITALS: PLEASE SHARE THIS WITH ALL YOUR EMERGENCY PREPAREDNESS STAFF NURSING HOMES: PLEASE SHARE THIS WITH ALL YOUR EMERGENCY PREPAREDNESS STAFF LOCAL HEALTH JURISDICTIONS: PLEASE DISTRIBUTE AS APPROPRIATE EMS COUNCILS: PLEASE DISTRIBUTE AS APPROPRIATE PROFESSIONAL HEALTH ORGANIZATIONS: PLEASE DISTRIBUTE TO YOUR MEMBERSHIP AS APPROPRIATE Severe Acute Respiratory Syndrome (SARS) This is an update to previous Pennsylvania Health Alerts issued March 17, 19, 21 and 25, 2003 1. Case Count CDC and WHO continue to issue updates on the national and international investigation of possible cases of SARS. The daily international summary is available at http://www.who.int/csr/sars/en/, and the national summary via the CDC main SARS web page at http://www.cdc.gov/ncidod/sars/. This week, the WHO international case count jumped dramatically. The latest WHO numbers now include almost 800 cases from Guangdong Province, China, going back to November 2002. It is certainly true that the number of new SARS cases under investigation continues to grow, including especially in Hong Kong. However, persons observing the increase in cases reported by WHO are cautioned to take into account the difference between reported date and onset date. As of March 26, CDC is reporting 45 “Suspected Cases Under Investigation” in the U.S., from 20 states including Pennsylvania. As of this update, two cases in Pennsylvania meeting the CDC surveillance case definition have been reported and investigated, and are now well. Additional reports of possible SARS cases are under investigation. No cases of severe illness nor secondary transmission of SARS in Pennsylvania are evident at this time. We thank Pennsylvania clinicians for continuing to contact their local public health authorities to report patients of concern. 2. Infection Control Update from CDC You attention is called to the following message from CDC: Interim Domestic Guidance for Management of Exposures to Severe Acute Respiratory Syndrome (SARS) for Healthcare and Other Institutional Settings Healthcare Settings 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 currently are 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 (http://www.cdc.gov/ncidod/sars/ic.htm). More general information on infection control in healthcare workers is available at http://www.cdc.gov/ncidod/hip/GUIDE/infectcont98.htm. CDC, in collaboration with state and local health departments, is developing a systematic approach for surveillance of SARS exposures and infection in healthcare workers for use by healthcare facilities. Additional information on surveillance materials will be forthcoming. Given the currently available information on the epidemiology of SARS in the United States, the following outlines interim guidance for the management of exposures to SARS in a healthcare facility. 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 avoi d contact with persons both in the facility and in the community (http://www.cdc.gov/ncidod/sars/infectioncontrol.htm). 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. 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 at http://www.cdc.gov/ncidod/sars/infectioncontrol.htm. 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. 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. Other Institutional Settings 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. 3. Etiology CDC and a number of other investigators worldwide continue to work on finding an etiology or etiologies for SARS. At this time, we are unable to offer more information than is being reported directly from CDC and by sources such as ProMED Mail (www.promedmail.org). It is not yet possible to resolve the discrepancy between some investigators who suggest a novel coronavirus as the agent of SARS, while others suggest a novel paramyxovirus. Until an agent is clearly established, a specific clinical diagnostic test will not be available. 4. EMS Infection Control The Pennsylvania Department of Health reminds all public safety personnel that the current practice in responding to a call involving respiratory distress or suspected pneumonia (including tuberculosis) is to follow contact and airborne precautions including gloves, N95/ HEPA filter respirators, and eye protection. In addition to current practices, EMS providers should question patients with the symptoms listed above as to any travel through Southeast Asia (or other areas with confirmed SARS cases) since February 1, 2003 and as to whether they have had contact with anyone who has been diagnosed with SARS. If a patient is suspected of having SARS, especially if there are confirmed cases of SARS in the region, gowns should be added to the above contact precautions. If practical, the patient should also wear a mask during transport. Following transport of a suspected SARS patient, providers should report their suspicions to the Emergency Department staff. Categories of Health Alert messages: Health Alert: conveys the highest level of importance; warrants immediate action or attention. Health Advisory: provides important information for a specific incident or situation; may not require immediate action. Health Update: provides updated information regarding an incident or situation; no immediate action necessary. This information is current as of March 27, 2003, but may be modified in the future. We will continue to post updated information regarding the most common questions about this subject.