A. Command and Control
Rapid and decisive action in response to a recurrence of SARS-CoV transmission
requires local, state, and federal public health authorities to work
efficiently and in concert toward the common goal of containing the spread
of infection. State and local officials provide the first line of response
with respect to preparing and planning for an outbreak at the jurisdictional
level; identifying, managing, and reporting cases; and exercising the
necessary authority to impose individual and community containment measures.
Given the complexity of responding to an outbreak of a serious respiratory
illness and the sustained, coordinated efforts required to control transmission,
states and localities must determine and clarify operational and legal
authorities in advance and make the necessary preparations for a multi-agency,
multi-jurisdictional response. Another essential preparedness step for
command, control, and coordination of resources during a SARS outbreak
response will be the development/adaptation of an incident management
structure supported by adequate information systems.
Goals
- Determine
and establish operational authority for the response to a SARS outbreak.
- Establish
an incident management structure for the response to a SARS outbreak,
supported by adequate information systems.
- Determine
and establish legal authority for a response to a SARS outbreak.
Priority Activities
- Conduct
local preparedness planning for a re-emergence of SARS-CoV, with participation
by persons representing a range of disciplines and expertise. Draft
and formally adopt a SARS response plan, or add SARS preparedness and
response to an existing preparedness plan.
- Confirm
the controlling authorities for actions such as declaring a public
health emergency, activating the SARS response plan, and curtailing
modes of transportation.
- Develop/reinforce
relationships with health authorities of adjoining jurisdictions and
with federal agencies to ensure effective communication and collaboration.
- Learn
about the legal authorities and statutes for enforcing individual and
community containment measures at the local, state, and federal levels.
- Develop/adapt
a predetermined incident command system to coordinate and manage SARS
response activities.
- Ensure
the availability of information system(s) that can document, support,
and coordinate the activities generated within an incident command
system (e.g., integrate personnel and facilities, expedite real-time
communication and flow of information, aid in logistics planning, resource
allocation
B. Surveillance
The SARS surveillance strategy is founded on complete and rapid identification
of cases -- the key to which is maintaining an appropriate index of suspicion
for SARS-CoV disease based on risk of exposure. With no known source
of transmission, the most likely sites of SARS-CoV recurrence are locations
where SARS-CoV transmission previously occurred, the original site of
introduction of SARS-CoV from animals to humans, laboratories in which
a break in technique leads to laboratory-acquired infections, and also
large international travel hubs that serve as interconnecting nodes to
high-risk locations.
The predilection for SARS-CoV transmission to occur among international
travelers and in healthcare settings and to cause unusual clusters of
pneumonia (Booth 2003; CDC 2003a; Hsu 2003; Lee 2003; Varia 2003) provides
a focus for surveillance in the absence of SARS-CoV transmission (i.e.,
patients requiring hospitalization for pneumonia, pneumonia in healthcare
workers, unusual clusters of pneumonia among travelers). If SARS-CoV
reappears, then patients or known sites of SARS-CoV transmission become
the most likely source of exposure. Contact tracing -- the identification
and evaluation of persons who had close contact with a potential SARS
case or were exposed to locations with known SARS-CoV transmission --
is important for the identification of persons at risk for SARS-CoV disease
and the initiation of appropriate measures to reduce the possible spread
of infection.
Goals
- Maximize
early detection of cases and clusters of respiratory infections that
might signal the global re-emergence of SARS-CoV disease while minimizing
unnecessary laboratory testing, concerns about SARS-CoV, implementation
of control measures, and social disruption.
- If
SARS-CoV transmission recurs, maintain prompt and complete identification
and reporting of potential cases to facilitate outbreak control and
management.
- Identify
and monitor contacts of cases of SARS-CoV disease to enable early detection
of illness in persons at greatest risk.
Priority Activities
- Educate
clinicians and public health workers on features that can assist in
early recognition of SARS and on guidelines for reporting SARS-CoV
cases.
- Develop
tools to identify, evaluate, and monitor contacts of SARS-CoV patients.
- Establish
an efficient data management system that links clinical, epidemiologic,
and laboratory data on cases of SARS-CoV disease and allows rapid sharing
of information.
- Identify
surge capacity for investigation of cases and identification, evaluation,
and monitoring of contacts in the event of a large SARS outbreak.
C. Preparedness and Response in Healthcare Facilities
In most
settings with large SARS outbreaks in 2003, healthcare facilities accounted
for a large proportion (often >50%) of cases (Booth
2003;
CDC 2003b; CDC
2003d; CDC
2003e). In addition to healthcare workers
who cared for patients, other hospital patients and visitors were often
affected and in many instances propagated the outbreaks in the hospital
and into the community. Therefore, rapid isolation of possible cases
of SARS-CoV disease and strict adherence to infection control precautions
are critical; prompt and decisive use of these measures has consistently
been a key and effective part of SARS control strategies. Each hospital
in a community should be prepared to identify, triage, and manage SARS
patients. Hospital-specific infection control policies related to SARS
should be guided by the level of SARS activity in the community and the
hospital. Identifying adequate resources and staff for an effective response
and surge capacity, if needed, are priorities.
Goals
- Rapidly
identify and isolate all potential SARS patients.
- Implement
infection control practices and contact tracing to interrupt SARS-CoV
transmission.
- Ensure
rapid communication within healthcare facilities and between healthcare
facilities and health departments.
Priority Activities
- Organize a planning committee to develop an institutional preparedness
and response plan and a clear decision-making structure.
- Develop surveillance, screening, and evaluation strategies for various
levels of SARS-CoV transmission.
- Develop plans to rapidly implement effective infection control measures
and contact-tracing procedures.
- Determine the current availability of infrastructure and resources
to care for SARS patients and strategies for meeting increasing demands.
- Develop strategies to meet staffing needs for SARS patient care and
management.
- Develop
strategies to communicate with staff, patients, the health department,
and the public.
- Develop strategies to educate staff and patients about SARS and SARS
control measures.
D. Community Containment Measures, Including Non-Hospital Isolation
and Quarantine
Community
containment strategies, including isolation, contact tracing and monitoring,
and quarantine, are basic infectious disease control measures that
proved to be critically important for control of the most severe SARS
outbreaks in 2003. Isolation of SARS patients separates them from healthy
persons and restricts their movement to prevent transmission to others,
preventing healthy persons from becoming ill. It also
allows for the focused delivery of specialized health care to ill persons. Quarantine
of persons who have been exposed to SARS-CoV but are not ill is intended
to prevent further transmission in the event that they develop SARS-CoV
disease by reducing the interval between the onset of symptoms and the
institution of appropriate precautions.
Given that
most SARS patients have a clearly identified exposure to other SARS
patients or to a setting with SARS-CoV transmission and that transmission
occurs after onset of illness, rapid identification of exposed persons
(contacts) and prompt isolation of contacts if they become ill is a
highly effective control strategy. Quarantine of contacts is often
a critical part of contact management and should be performed selectively,
carefully, and with respect for human dignity. Isolation and quarantine
are optimally performed on a voluntary basis, but many levels of government
(local, state, federal) have the basic legal authority to compel mandatory
isolation and quarantine of persons and communities when necessary to
protect the public's health. Broader community containment through "snow
day" measures, such as cancellation of public gatherings and closure
of school and businesses, can also be used to reduce transmission by
limiting social interactions at the population level. The rationale for
such measures, as well as mechanisms to ensure due process and prevent
stigmatization of affected persons, need to be clearly articulated.
Goal
- Prevent
transmission of SARS-CoV through use of a range of community containment
strategies chosen to provide maximum efficacy based on the characteristics
of the outbreak while minimizing the adverse impact on civil liberties.
Priority Activities
- Identify, evaluate, and monitor contacts of SARS patients, and consider
quarantine of contacts if needed.
- Continually monitor the course and extent of the outbreak, and evaluate
the need for community containment measures.
- Establish the infrastructure to deliver essential goods and services
to persons in quarantine and isolation.
- Develop tools and mechanisms to prevent stigmatization and provide
mental health resources for those in isolation and quarantine.
- Work with community partners to ensure that implementation and communication
plans address the cultural and linguistic needs of affected persons.
E. Prevention of International Travel-Related Transmission Risk
In the absence of control measures, SARS-CoV can spread rapidly on a
global scale through international travel. Screening and evaluating passengers
for SARS-like symptoms, educating them about SARS, and reporting illnesses
in travelers can decrease the risk of travel-associated infections.
Goals
- Prevent
the introduction of SARS-CoV (and spread from an introduction) into
the United States from SARS-affected areas.
- Prevent
exportation of SARS-CoV from the United States if domestic transmission
presents an increased risk of exportation.
- Reduce
the risk of SARS-CoV disease among outbound travelers to SARS-affected
areas.
- Prevent
the transmission of SARS-CoV to passengers on a conveyance with a SARS
patient, and evaluate and monitor other passengers to detect SARS-like
illness and prevent further spread.
Priority Activities
- Screen
incoming travelers from SARS-affected areas for SARS, and provide guidance
about monitoring their health and reporting illness.
- Provide
guidance to outbound travelers about active SARS-affected areas and
measures to reduce risk of acquiring SARS-CoV disease during travel.
- If
SARS-CoV transmission in the United States presents an increased risk
of exporting SARS-CoV to other countries, then screen outbound travelers
to prevent such exportation.
- Ensure
the appropriate evaluation and management of SARS cases and potentially
exposed passengers and crew members on conveyances.
F. Laboratory Diagnostics
Laboratory
diagnostics are essential for detecting and documenting a resurgence
of SARS, responding to and managing SARS outbreaks, and managing
concerns about SARS-CoV disease in patients with other respiratory
illnesses. The identification of the etiologic agent, SARS-CoV,
led to rapid development of enzyme immunoassays (EIA) and immunofluorescence
assays (IFA) for SARS antibody (Ksiazek
2003) and reverse-transcriptase PCR (RT-PCR) assays
for SARS-CoV RNA (Emery 2004). These assays can be very sensitive and
specific for detecting antibody and RNA, respectively, but are less sensitive
for detecting infection, especially early in illness. Diagnostic assays
for other respiratory pathogens may be helpful in differentiating SARS-CoV
disease from other illnesses, but SARS patients may be simultaneously
infected with SARS-CoV and another respiratory pathogen. CDC's laboratory
diagnostics plan is based on the following goals and activities:
Goals
- Provide
the public health community with ready access to high-quality SARS-CoV
diagnostics.
- Ensure
that SARS-CoV laboratory diagnostics are used safely and appropriately
and that results are interpreted appropriately.
Priority Activities
- Improve the ability to detect SARS-CoV infection by optimizing the
selection and timing of specimen collection and processing.
- Provide SARS-CoV assays for RT-PCR testing through Laboratory Response Network (LRN) laboratories and for serologic testing to state public
health laboratories.
- Distribute proficiency panels and questionnaires to participating
laboratories to determine the ability of laboratories to provide valid
SARS-CoV diagnostics.
- Provide guidance on laboratory safety for SARS-CoV and other respiratory
diagnostic testing and for potentially SARS-CoV-containing specimens
submitted for other tests.
- Provide guidance for interpreting test results, taking into account
the potential for false-positive and false-negative results and the
availability of applicable clinical and epidemiologic information.
- Identify surge capacity for laboratory testing in the event of a
large SARS outbreak.
G. Communication and Education
Rapid and
frequent communication of crucial information about SARS -- such as
the level of the outbreak worldwide and recommended control measures
-- are vital components of efforts to contain the spread of SARS-CoV.
Specific communication needs and key messages will vary substantially
by level of SARS activity. In the absence of SARS-CoV transmission globally,
the preparation and dissemination of messages and materials are designed
to maintain vigilance in the healthcare community and general awareness
among all parties about the possibility of a SARS outbreak and the steps
that would be indicated in such an event. The recurrence of SARS-CoV
transmission anywhere in the world will generate immediate and intense
media attention and require an enormous effort to respond to the demand
from the public, the media, policymakers, and healthcare workers for
information and guidance. A domestic outbreak of SARS will result in
even greater demands to manage media requests, disseminate up-to-date
outbreak information and messages, assist local hospitals and healthcare
providers in responding to the public, and respond to inquiries from
special interest groups.
Goals
- Instill
and maintain public confidence in the nation's public health system
and its ability to respond to and manage the reappearance of SARS-CoV.
- Contribute to the maintenance of order, minimization of public panic
and fear, and facilitation of public protection through the provision
of accurate, rapid, and complete information before, during, and after
a SARS outbreak.
- Provide accurate, consistent, and comprehensive information about
SARS-CoV disease.
- Address
rumors, inaccuracies, and misperceptions as quickly as possible,
and prevent stigmatization of specific groups.
Priority Activities
- Identify key messages about SARS-CoV disease for specific audiences
and the most effective methods to deliver these messages.
- Issue local public health announcements and updated information on
the outbreak and response.
- Provide a location for state, local, and federal communication and
emergency response personnel to meet and work side-by-side in developing
key messages and handling media inquiries.
- Respond to frequently occurring media questions by preparing fact
sheets, talking points (key messages), and question-and-answer documents.
- Coordinate requests for spokespersons and subject matter experts.
H. Plans for SARS Investigations and Epidemiologic Research
[This section is currently under development.]
I. Infection Control in Healthcare, Home, and Community Settings
Transmission of SARS-CoV in healthcare settings was a major factor in
the propagation of the 2003 global SARS epidemic. In each of the major
outbreak areas, SARS-CoV caused unprecedented levels of morbidity and
mortality among healthcare personnel and disrupted healthcare delivery
systems. Rapid implementation and adherence to infection control measures
proved essential for controlling transmission in healthcare facilities
and containing the outbreaks. Ensuring readiness for a reappearance for
SARS-CoV therefore means maintaining emphasis on the importance of infection
control in healthcare facilities and correcting any deficiencies in infection
control training and practice.
If person-to-person SARS-CoV transmission recurs, many patients may
be isolated in residential settings. In the United States, hospitalization
of patients with SARS-CoV disease is recommended only when medically
indicated. Given the risk of exposure to household members, strict infection
control measures are also needed to prevent SARS-CoV transmission from
patients isolated in residential settings. In addition, if a large outbreak
overwhelms the capacity of the healthcare system, patients may be isolated
in community facilities. As in the case of healthcare and residential
settings, appropriate infection control measures will be required to
prevent transmission of infection in these facilities.
Goals
- Ensure
early recognition of patients at risk for SARS-CoV disease.
- Prevent
transmission of SARS-CoV by implementing appropriate infection control
precautions.
Priority Activities
- Reinforce
basic infection control practices among healthcare workers.
- Take
steps to reduce transmission of respiratory viruses from symptomatic
persons at the time of initial encounter with the healthcare setting.
- Develop
triage strategies that ensure early recognition of patients at risk
for SARS-CoV disease.
- Develop
plans for appropriate SARS infection control precautions in inpatient
and outpatient healthcare facilities, homes, and community isolation
facilities.
- Ensure
appropriate management and follow-up monitoring of healthcare workers
who have had exposures to and other contacts with SARS patients.
J. Information Technology
During the 2003 epidemic, the internet played an important part in global
efforts to identify the etiologic agent of SARS and control its spread.
Unfortunately, in many outbreak settings, the lack of useful information
management systems made outbreak control less efficient in many areas
and in some instances may have actually delayed the containment and control
of SARS. Although a web-based system to manage all aspects of a SARS
outbreak would be ideal, issues of confidentiality, data security, data
ownership, and availability of technical expertise to support new information
systems make the ideal system a long-term goal. In the short term, a
web-based case reporting system -- plus efficient means to link clinical,
epidemiologic, and laboratory data -- will provide an efficient process
for quickly recording and reporting the status of SARS activity in the
United States for federal, state, and local response needs.
Rapid identification, tracking, evaluation, and monitoring of contacts
of SARS cases will be key to early detection of symptoms in persons at
greatest risk of SARS, and development of a data management system to
facilitate this process is vital. Contact tracing can be particularly
challenging and resource intensive in large-scale outbreaks or among
highly mobile populations such as international travelers. Ideally, such
a system should be integrated with the case reporting system to allow
rapid exchange of information. Finally, the tracking of contacts of SARS
cases on conveyances (e.g., airplanes) will require rapid availability
of electronic passenger manifests that provide information on the proximity
of the contact to the case. This information needs to be rapidly assimilated
and disseminated to a large number of state and local health departments
for notification and monitoring of contacts.
Goal
- Deploy an integrated data management system that efficiently and
effectively supports SARS outbreak response needs at the federal, state,
and local levels.
Priority Activities
- Develop and deploy a case-reporting system for SARS surveillance
that supports federal, state, and local health department needs and
makes data readily available to the submitting health department. The
system can be based on either web-based data entry or data downloads.
- Implement an outbreak-management system that can track and link clinical,
laboratory, and epidemiologic data and can be used to monitor all aspects
of an outbreak response at the local level. The system should allow
state and local health departments to track the monitoring and follow-up
of contacts for clinical illness and compliance with isolation and
quarantine measures, as applicable.
- Collaborate with the Department of Transportation to rapidly obtain
passenger manifests for conveyances with ill travelers.
- Use electronic
communication mechanisms (e.g., Epi-X, Health Alert Network) to disseminate
contact information to state and local health departments.
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