Health Update
SARS UPDATE AND CDC INTERIM GUIDANCE ON USE OF RESPIRATORS TO PREVENT TRANSMISSION OF SARS

This SARS Update from the Delaware Division of Public Health (DPH) contains three items:

• Update #1: Updated Interim U.S. Case Definition of Severe Acute Respiratory Syndrome (SARS)
• Update #2: Delaware SARS Update and Clarification Regarding When to Seek Medical Care for SARS, to Limit Activities Outside the Home, or Be Excluded from School or Work
• Update #3: Interim Domestic Guidance on the Use of Respirators to Prevent Transmission of SARS, also from the CDC.

The following resources are available for help with questions about SARS:

• DPH: (888) 295-5156 (This telephone number is staffed during business hours and for emergencies during non-business hours)
• CDC SARS Website: http://www.cdc.gov/ncidod/sars
• CDC public response hotline: (888) 246-2675 (English), (888) 246-2857 (Español), or (866) 874-2646 (TTY)

Update #1
Updated Interim U.S. Case Definition of Severe Acute Respiratory Syndrome (SARS)

Distributed via Health Alert Network
April 18, 2003, 18:06 EDT (06:06 PM EDT)
CDCHAN-00136-03-04-18-UPD-N

The Centers for Disease Control and Prevention (CDC) has made two modifications to the U.S. case definition of SARS as follows:

1. CDC has added Toronto, Canada to the list of areas with documented or suspected community transmission of SARS. This is in response to reports that SARS has resulted in serious illness among some members of the Bukas-Loob Sa Diyos (BLD) Covenant Community who attended a large gathering in Toronto on March 28 - 29, 2003. According to public health officials in the City of Toronto, SARS has been diagnosed among members of their households as well as other close contacts.
   
   BLD has multiple outreach areas throughout the United States (Reno, NV, Seattle, WA, Oakland, CA, Albany, NY, Trenton, NJ, Long Island, NY, Los Angeles, CA and the metro DC (Maryland /Virginia/Washington DC) area. Therefore, state and local health officials are advised to be alert for cases of SARS among persons who traveled to Toronto and participated in events sponsored by the BLD Community. Such cases should be reported to CDC. Toronto health officials are continuing to compile a complete listing of attendees who attended formal and informal events organized for the BLD Community.
   
   Public health officials in Pennsylvania have notified CDC of a probable case of SARS in a resident who traveled to Toronto and attended BLD Community events during March 28 - 30. This person was hospitalized with pneumonia on April 14; a serum sample was obtained and has tested positive for coronavirus antibody. CDC is working with public health officials in Pennsylvania to conduct a comprehensive investigation including the notification of all potential contacts of the infected Pennsylvania resident.
2. U.S. cases of SARS will now be classified as either suspect or probable as outlined in the attached updated interim CDC case definition. Local and state health departments are requested to continue reporting all (i.e., both suspect and probable) cases of SARS. Although CDC will continue to report both suspect and probable cases to WHO, we anticipate that WHO will include only probable cases in its daily case report.

The Updated Interim U.S. SARS Case Definition is as follows:

Suspect Case

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

• Measured temperature greater than 100.4 °F (greater than 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 a person known to be a suspect SARS case.

Probable Case

A suspect case with one of the following:

• Radiographic evidence of pneumonia or respiratory distress syndrome
• Autopsy findings consistent with respiratory distress syndrome without an identifiable cause

†Travel includes transit in an airport in an area with documented or suspected community transmission of SARS

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; Singapore; and Toronto, Canada.

*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.

Update #2
Delaware SARS Update and Clarification Regarding When to Seek Medical Care for SARS, Limit Activities Outside the Home, or Be Excluded from School or Work

Distributed via the Delaware Health Alert Network
April 21, 2003

Recent calls to Delaware's Division of Public Health (DPH) indicate heightened concern regarding Severe Acute Respiratory Syndrome (SARS) among Delaware residents and employers. Delaware hospitals have reported an increase in questions about the need for isolation and quarantine and in requests for surgical masks for use as protective devices.

Although various respiratory illnesses persist in the community, no cases of SARS have been identified in Delaware since the disease was first described in March by the Centers for Disease Control and Prevention (CDC).

DPH continues to monitor disease trends and suspect SARS cases in Delaware to assure appropriate and immediate steps for reducing the potential for transmission. The CDC advises that people planning non-essential travel to mainland China, Hong Kong, Singapore, and Hanoi, Vietnam postpone their trips until further notice. The following information indicates when residents should seek medical help or remain at home because of a potential for SARS infection.

Travelers to mainland China, Hong Kong, Singapore Hanoi, Vietnam and Toronto, Canada or those who have come into contact with someone known to have SARS should monitor their own health and seek medical attention only if they develop the following symptoms within 10 days:

• Fever over 100.4 F AND
• One or more of the following: cough, shortness of breath, difficulty breathing, tests indicating low levels of oxygen in the blood, or X-ray findings of pneumonia or acute respiratory distress.

There is no reason to seek medical care for SARS, to limit activities outside the home, or be excluded from school or work for persons who:

• Have not traveled to these countries or have not had contact with someone known to have SARS, even if they have the symptoms described above. (However, such persons may need to consult their primary health care provider because the symptoms could suggest a health problem other than SARS.)
• Do not have the symptoms described above, even if they have traveled to these countries or have had contact with someone known to have SARS.

Update #3
Interim Domestic Guidance on the Use of Respirators to Prevent Transmission of SARS

Distributed via Health Alert Network
April 19, 2003, 15:35 EDT (03:35 PM EDT)
CDCHAN-00137-03-04-19-UPD-N

Health-care workers caring for patients with Severe Acute Respiratory Syndrome (SARS) are at risk for acquiring SARS. Although the infectivity of SARS is currently uncertain, transmission to health-care workers appears to have occurred after close contact with symptomatic individuals (e.g., persons with fever or respiratory symptoms), particularly before implementation of recommended infection control precautions for SARS (i.e., unprotected exposures). Personal protective equipment appropriate for standard, contact, and airborne precautions (e.g., hand hygiene, gown, gloves, and N95 respirators) in addition to eye protection, have been recommended for health-care workers to prevent transmission of SARS in health-care settings (see http://www.cdc.gov/ncidod/sars/ic.htm).

The transmission of SARS appears to occur predominantly by direct contact with infectious material, including dispersal of large respiratory droplets. However, it is also possible that SARS can be spread through the airborne route. Accordingly, CDC has recommended the use of N95 respirators, consistent with respiratory protection for airborne diseases, such as tuberculosis.

SARS, unlike tuberculosis, also appears to spread by direct contact with respiratory secretions, which makes touching contaminated objects a potential concern. Although reaerosolization of infectious material is unlikely under normal use conditions, infectious material deposited on a respirator may cause it to become a vehicle for direct or indirect transmission. Therefore, additional infection control measures applicable to this specific situation are needed.

This interim guidance provides information on the selection and handling of respirators for SARS and includes guidance for when respirators are either not available or in short supply.

1. A NIOSH-certified, disposable N-95 respirator is sufficient for routine airborne isolation precautions. Use of a higher level of respiratory protection may be considered for certain aerosol-generating procedures (see http://www.cdc.gov/ncidod/sars/aerosolinfectioncontrol.htm)
   
   1. Respirators should be used in the context of a complete respiratory protection program in accordance with OSHA regulations. This includes training and fit testing to ensure a proper seal between the respirator's sealing surface and the wearer's face. Detailed information on respirator programs, including fit test procedures can be accessed at: http://www.osha.gov/SLTC/etools/respiratory
   2. Once worn in the presence of a SARS patient, the respirator should be considered potentially contaminated with infectious material, and touching the outside of the device should be avoided. Upon leaving the patient's room, the disposable respirator should be removed and discarded, followed by hand hygiene.
2. If a sufficient supply of respirators is not available, healthcare facilities may consider reuse as long as the device has not been obviously soiled or damaged (e.g., creased or torn). Data on reuse of respirators for SARS are not available. Reuse may increase the potential for contamination; however, this risk must be balanced against the need to fully provide respiratory protection for healthcare personnel.
   
   If N95 respirators are reused for contact with SARS patients, implement a procedure for safer reuse to prevent contamination through contact with infectious droplets on the outside of the respirator.
   
   1. Consider wearing a loose-fitting barrier that does not interfere with fit or seal (e.g., surgical mask, face shield) over the respirator.
   2. Remove the barrier upon leaving the patient's room and perform hand hygiene. Surgical masks should be discarded; face shields should be cleaned and disinfected.
   3. Remove the respirator and either hang it in a designated area or place it in a bag. (Consider labeling respirators with a user's name before use to prevent reuse by another individual.)
   4. Use care when placing a used respirator on the face to ensure proper fit for respiratory protection and to avoid contact with infectious material that may be present on the outside of the mask.
   5. Perform hand hygiene after replacing the respirator on the face.
3. When reusable respirators (e.g., elastomeric [rubber], powered air purifying respirators [PAPR]) are used, the reusable elements should be cleaned and disinfected after use, in accordance with manufacturer's recommendations. In addition, if reusable respirators are used by more than one individual, filters must be replaced between individual users. The used filters must be safely discarded.
4. Respiratory protective devices with a filter efficiency of 95% or greater (e.g., N95, N99, N100) may not be available in some settings due to supply shortages or other factors. In this situation, a surgical (procedure) mask should be worn. Surgical masks will provide barrier protection against large droplets that are considered to be the primary route of SARS transmission. However, surgical masks may not adequately protect against aerosol or airborne particles, primarily because they allow for leakage around the mask and cannot be fit tested. The mask should resist fluid penetration and fit tightly around the mouth and nose when properly applied to the face.
5. Hand hygiene is urged for all contact with suspect SARS patients or objects that may be contaminated with the virus that causes SARS, including hand washing with soap and water; if hands are not visibly soiled, alcohol-based hand rubs may be use as an alternative to hand washing.