Health Update
SARS UPDATE WITH DELAWARE SPECIFIC INFORMATION

Severe Acute Respiratory Syndrome (SARS) Update

Suspected cases of SARS reported in U.S. CDC has reported to the World Health Organization (WHO) 11 suspected cases of Severe Acute Respiratory Syndrome (SARS). The cases, reported by clinicians from 10 states, meet the case definition established by the WHO. CDC continues to work with state health officials and clinicians to evaluate these cases.

Note: Case numbers may fluctuate as the investigation proceeds and more knowledge is gained. CDC will update case counts regularly on its web site in order to be consistent with its reporting to the WHO.

Laboratory Findings of a Paramyxovirus

Findings in Germany and Hong Kong suggesting that a paramyxovirus may be playing a role in the SARS outbreak appear promising. CDC laboratorians advise caution, however, in altering treatment modalities based on this information. Samples used in these tests were obtained from the naso-pharynx, and tissue sample testing has not yet been completed. CDC advises clinicians not to assume they are treating SARS or a paramyxovirus infection, but rather to evaluate patients with an open mind and treat them with the appropriate antimicrobial therapy that they would use for any case of serious community acquired atypical pneumonia until additional information is available to help guide them.

Quarantine Safety Net Expands

CDC quarantine officers are expanding the safety net to meet more flights returning from Southeast Asia. Since Sunday, CDC quarantine officers or their designees have been meeting travelers returning directly to the U.S. from Hong Kong on commercial carriers that land at 5 U.S. airports (Chicago, Los Angeles, Newark, New York City, San Francisco) to give them health information in the event they exhibit symptoms of SARS. No commercial flights return directly to the United States from Hanoi, Vietnam or Goungdong Province China. Quarantine officers or their designees are now meeting passengers landing from Hong Kong in Anchorage and Guam, and coverage has expanded to include travelers returning on commercial flights that have connecting service from affected areas of Southeast Asia and is further expanding to include cargo and cruise ships returning to U.S. ports.

Hong Kong Makes Link Between SARS Cases and Hotel Stay

The Hong Kong Department of Health has reported 7 individuals who contracted SARS are now known to have stayed on or visited the 9th floor of the Metropole Hotel in Kowloon in the period between February 12 and March 2. Hotel staff has reported no subsequent illness. CDC is in communication with Hong Kong officials as well as WHO investigators as the significance of the hotel connection is explored. Based on this report, as well as experience with the case patients who traveled to Georgia and New York City, who also stayed in hotels, CDC continues to believe that close contact is an important factor in disease transmission.

For more information on SARS, visit the CDC web site at:  http://www.cdc.gov/ncidod/sars/

On Thursday, March 20, 2003, a Morbidity and Mortality Weekly Report (MMWR) will be published with more information on SARS.

Severe Acute Respiratory Syndrome (SARS) / Atypical Pneumonia

Hospitals are reporting daily the frequency of symptoms consistent with this syndrome. However, we are asking healthcare providers/practitioners be vigilant for possible cases.

Please be alert for patients 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 Peoples Republic of China, Hanoi or 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.

Please contact the DPH Epidemiology Branch at 1-888-295-5156 or (302) 744-4541 with any concerns or information relating to suspect cases. Please have the following information available when calling:

• Date of birth
• Sex
• Onset date of illness
• Clinical status
• If expired, date of death and whether an autopsy was performed
• Did patient require mechanical ventilation?
• Is the patient a healthcare worker?
• If patient is a healthcare worker, place of employment
• Possible epidemiologic ties to other cases (dates and places for recent travel, dates and type of exposure for those exposed to other ill persons, and if available, ID information for the presumed source of their infection)
• Type of specimens available

Infection Control

As per CDC recommendations, infection control measures for any suspect case admitted to the hospital should include the following:

• Immediate notification of infection control personnel
• Airborne precautions (isolation room with negative pressure and use of an N-95 respirator for all persons entering the room)
• Contact precautions (gown, gloves, eye protection and meticulous hand hygiene)

Non-hospitalized suspect patients should limit their interaction outside the home until the epidemiology of illness transmission is better understood. Placing a surgical mask on suspect cases in ambulatory healthcare settings, during transport, and during contact with others at home is prudent.

Specimen Collection

The following clinical specimens should be collected in consultation with the Delaware Public Health Laboratory to be forwarded to the CDC for examination:

• Frozen and formalin fixed tissues from an autopsy
• Transbronchial or pleural biopsy specimens fixed in formalin
• Bronchioaveolar lavage (BAL) specimens, spun with supernatant frozen and cell pellet fixed in formalin
• Acute and convalescent serum samples, either at room temperature, iced or frozen
• Peripheral blood smear, dried, at room temperature
• Nasopharyngeal wash or throat swab in viral transport medium, frozen

Whenever possible, packaging procedures for SARS specimens submitted to the Delaware Public Health Laboratory should follow those used for tuberculosis specimens:

• Specimen is placed in a leak-proof primary container, then wrapped in absorbent material
• This is then placed in a rigid, secondary screw-top container
• This secondary container is then placed in a tertiary screw-top container to be labeled "BIOHAZARD"

All containers should be double-checked to assure lids are securely fastened.

Treatment

Because the etiology of these illnesses has not 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 of choice may be influenced by illness severity. Infectious disease consultation is recommended.

Reporting

Please contact the Delaware Division of Public Health, Epidemiology Branch:

• 1-888-295-5156 (Delaware only)

OR

• 302-744-4541