Health Advisory
THIRD POSSIBLE SARS CASE REPORTED IN CHINA;
INFLUENZA A (H5N1) INFECTIONS REPORTED IN VIETNAM

This advisory contains information from the Centers for Disease Control and Prevention CDC about two topics:

• A third possible case of SARS has been reported in China.  CDC is recommending that U.S. physicians maintain a greater index of suspicion of SARS in patients who require hospitalization for radiographically confirmed pneumonia or acute respiratory distress syndrome (ARDS) AND who have a history of travel to Guangdong Province (or close contact with an ill person with a history of recent travel to Guangdong Province) in the 10 days before onset of symptoms.
• Human avian influenza has been identified in Vietnam.  There is no evidence at this time of human-to-human transmission.  CDC recommends that clinicians identify patients who have been hospitalized with unexplained pneumonia, ARDS, or severe respiratory illness AND who have traveled to Vietnam, South Korea, and Japan within 10 days from onset of symptoms.

Additional information is provided below, including actions that should be taken if such patients are identified, and advice for travelers.

In Delaware, for questions, technical assistance, or to report an event, please call DPH at 1-888-295-5156.  This number is available during normal business hours and during nonbusiness hours for emergencies.

This is an official
CDC Health Advisory

Distributed via Health Alert Network
January 14, 2004,20:32 EST (08:32 PM EST)
CDCHAN-00183-04-01-14-ADV-N

This advisory provides updated information and recommendations following recent reports of cases of severe acute respiratory syndrome (SARS) in Guangdong Province, China, and human cases of influenza A(H5N1) virus infections in Vietnam. No travel alerts or advisories to these regions have been issued by the Centers for Disease Control and Prevention (CDC), but increased vigilance is advised for ill persons traveling to the United States from Guangdong Province and Vietnam, Japan, and South Korea.

Severe Acute Respiratory Syndrome

Recent SARS Cases in China

On January 13, 2004, the Chinese Ministry of Health (MOH) and the World Health Organization (WHO) reported a new suspect case SARS in a 35-year-old man living in Guangdong Province, China. This case is the third recent report of suspected or confirmed SARS in patients in southern China. No link has been established at present between the confirmed case and the two recent suspect SARS cases, and the source of exposure for all three cases is unclear.

On January 5, 2004, Chinese and WHO authorities announced that laboratory results confirmed evidence of SARS-associated coronavirus infection (SARS-CoV) in a 32-year-old man in Guangdong Province who had become ill on December 16, 2003. On January 8, 2004, a suspect case of SARS was reported in a 20-year-old woman who works in a restaurant in Guangdong Province and had onset of illness on December 25, 2003. On January 12, 2004, a suspect case of SARS was reported in a 35-year-old man from Guangdong Province who had onset of illness on December 31, 2003, and was admitted to Guangdong People’s Hospital and placed in isolation on January 6. All three patients are reported to be doing well, and no signs or symptoms of SARS-like illness have been reported among their identified contacts to date. Details on the clinical features and laboratory results of the 2 suspect SARS cases are not yet available.

Recommended U.S. SARS Control Measures

In light of these reports, the CDC is recommending that U.S. physicians maintain a greater index of suspicion of SARS in patients who require hospitalization for radiographically confirmed pneumonia or acute respiratory distress syndrome (ARDS) AND who have a history of travel to Guangdong Province (or close contact with an ill person with a history of recent travel to Guangdong Province) in the 10 days before onset of symptoms. When such patients are identified, the following actions should be taken:

• Patients should immediately be placed in appropriate isolation precautions for SARS (i.e., contact and airborne precautions)
• Patients should promptly be reported to the state or local health department
• Patients should promptly be tested for evidence of SARS-CoV infection as part of the diagnostic evaluation (see Appendix 2 ”Updated Guidelines for Collecting Specimens from Potential SARS Patients,” in the CDC document, “In the Absence of SARS-CoV Transmission Worldwide: Guidance for Surveillance, Clinical and Laboratory Evaluation, and Reporting” at: www.cdc.gov/ncidod/sars/absenceofsars.htm
• The health department should identify, evaluate, and monitor relevant contacts of the patient, as indicated. In particular, the health status of household contacts or persons who provided care to symptomatic patients should be assessed.

In addition, CDC continues to recommend that health care providers and public health officials identify and report patients who require hospitalization for radiographically confirmed pneumonia or ARDS without identifiable etiology AND who have one of the following risk factors in the 10 days before the onset of illness:

• Travel to mainland China, Hong Kong, or Taiwan, or close contact with an ill person with a history of recent travel to one of these areas, OR
• Employment in an occupation associated with a risk for SARS-CoV exposure (e.g., health care worker with direct patient contact; worker in a laboratory that contains live SARS-CoV), OR
• Part of a cluster of cases of atypical pneumonia without an alternative diagnosis.

Diagnostic testing for SARS should be considered in such patients, as described in the guidelines at:   www.cdc.gov/ncidod/sars/absenceofsars.htm .  Infection control practitioners and other health care personnel should also be alert for clusters of pneumonia among two or more health care workers who work in the same facility.

Advice for Travelers (SARS)

At this time, WHO and CDC have not issued any alerts or advisories for travel to China www.cdc.gov/ncidod/sars/travel_alertadvisory.htm   Previous SARS research has shown that SARS can be controlled and contained through early detection, isolation of suspect cases, and tracing of their contacts.

On the basis of limited available data, it would be prudent for travelers to China to avoid visiting live food markets and avoid direct contact with civets and other wildlife from these markets. Although there is no evidence that direct contact with civets or other wild animals from live food markets has led to cases of SARS, viruses very similar to SARS-CoV-the virus that causes SARS-have been found in these animals. In addition, some persons working with these animals have evidence of infection with SARS-CoV or a very similar virus.

US Bans Importation of Civet Cats

On January 13, 2004, the Department of Health and Human Services (HHS) announced an immediate embargo on the importation of civets to the United States http://www.cdc.gov/ncidod/sars/civet_ban_exec_order.htm. These small animals have been identified as a possible link to SARS transmission in China. The embargo, which applies to dead and live civets as well as civet products, will remain in place until further notice. Civet products that have been processed to render them noninfectious, such as fully taxidermied animals and finished trophies, are not included in the embargo. The ban does not apply to civet cats approved by CDC for importation for educational or scientific purposes.

More Information About SARS

For more information about current U.S. SARS control guidelines, see the CDC document, “In the Absence of SARS-CoV Transmission Worldwide: Guidance for Surveillance, Clinical and Laboratory Evaluation, and Reporting” at:  www.cdc.gov/ncidod/sars/absenceofsars.htm .  The document is part of CDC’s draft "Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS)"  and can be found at:  www.cdc.gov/ncidod/sars/sarsprepplan.htm

For additional information about the reported SARS cases in China, see the Web sites of CDC at: www.cdc.gov and WHO at: www.who.int/en/

Influenza A (H5N1) Virus Infections

Recent Influenza A (H5N1) Cases

Since the end of October 2003, 14 persons (13 children and 1 adult) in Vietnam have been admitted from surrounding provinces to hospitals in Hanoi for severe respiratory illness. Among the 14 patients, three (2 children and 1 adult) have had avian influenza A (H5N1) virus infections confirmed by testing conducted at the National Institute of Hygiene and Epidemiology in Hanoi and in Hong Kong. Twelve of the patients, including 11 children and the mother of one of the deceased children, have died.

Influenza A (H5N1) viruses normally circulate among wild birds but can infect poultry and rarely have infected people in the past. In 1997, 18 persons in Hong Kong were hospitalized because of influenza A (H5N1) infections and six of them died. In 2003, two residents of Hong Kong who traveled to China developed influenza A (H5N1) virus infections and one of them died. In Vietnam, large outbreaks of influenza A (H5N1) have been reported among poultry in the southern and northern regions of the country. WHO has reported that the H5N1 strain implicated in the outbreak has now been partially sequenced. All genes are of avian origin, indicating that the virus that caused death in the three confirmed cases had not yet acquired human genes. The acquisition of human genes increases the likelihood that a virus of avian origin can be readily transmitted from one human to another.

Staff from CDC will travel to Vietnam to work with WHO and Vietnam’s human and animal health authorities to evaluate the situation, including patternsoftransmission of the influenza A (H5N1) viruses.

During December 2003, an outbreak of avian influenza A (H5N1) was reported among poultry in South Korea. Earlier this week, Japan reported the deaths of 6,000 chickens on a single farm in the western part of Honshu due to influenza A (H5N1) virus infection. No human cases of infection with the avian influenza virus have been reported in either of these outbreaks.

Enhanced U.S. Influenza Surveillance

At this time, CDC recommends enhanced surveillance efforts by state and local health departments, hospitals, and clinicians to identify patients who have been hospitalized with unexplained pneumonia, ARDS, or severe respiratory illness AND who have traveled to Vietnam, South Korea, and Japan within 10 days from onset of symptoms

All such patients should be tested for influenza virus infection; these tests should include viral culture of nasopharyngeal and throat swabs. All influenza A viruses should be subtyped, and those that cannot be identified as H3 or H1 viruses should be sent immediately to CDC for testing for influenza A (H5N1).

CDC will make additional recommendations on enhanced surveillance if influenza A (H5N1) activity continues to evolve.

SARS and Influenza A(H5N1)

There is considerable potential for the clinical presentation and travel history of persons with either SARS or influenza A (H5N1) infection to overlap. Therefore, the following actions should be taken:

• Influenza A infection should be considered in the differential diagnosiswhen evaluating a SARS patient.
• Laboratories should make subtyping of influenza A viruses isolated from potential SARS cases a priority.
• The laboratory should immediately notify the CDC’s Influenza Branch if any influenza A virus cannot be subtyped.

More Information About Influenza

For further details about the reported cases of influenza A (H5N1) in Vietnam, see the WHO Web site at:  www.who.int/en/ .  Additional information about influenza is available on the CDC Web site at:  www.cdc.gov .