CDC0508.03
Hello, I'm Dr. Julie Geberding, director of the Centers for Disease
Control and Prevention. Thank you for
joining us today for a clinical update on severe acute respiratory syndrome. Front
line physicians and local and state health officials have been stellar in their
response to this outbreak. Your hard work is paying off. We are managing to contain this outbreak
right now. But we must, of course,
remain vigilant. Our greatest concern
continues to be those who have been their directly affected by this illness,
the infected individuals, their families and loved ones. We extend our heart-felt sympathy to these
people, and at the same time express our resolve to continue to seek answers to
this global epidemic. Like many new
infectious diseases, the outbreak of sars has been followed by an outbreak of
fear. This fear is initiating
discrimination against those whom the public perceives to be most at risk for
contracting and transmitting the disease.
We must all emphasize that the culprit here is the virus, not
communities or racial groups. We are
cautiously optimistic that sars can be contained. Our strategy focuses on early detection and
isolation of suspect cases and active monitoring of exposed persons during the
ten-day incubation period. cdc continues
to work in collaboration with the World Health Organization as well as with
other international colleagues to investigate all aspects of the sars
outbreak. We have come a long way in a
very short time, but we realize that there is still a tremendous amount to
learn about this new virus. Please refer
to the WHO and cdc web sites for the most current information on sars. I thank you for joining us today and for the
work you do everyday in the fight against this global health problem.
Hello, everyone. I'm Kysa Daniels.
Welcome to "Increasing Clinician Preparedness For Severe Acute
Respiratory Syndrome -- sars". We
are coming to you live from the Centers For Disease Control and Prevention in
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call us here at cdc at 800-728-8232.
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A certificate of credit or a certificate of attendance will be awarded
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For the purposes of disclosure, today's speakers have stated that they
have no financial interest or other relationships with any commercial products
or services. Coming up in just a few
minutes, Dr. John Jernigan will mention an
off label use of a product. He will
mention that some clinicians have used ribavirin in an off-label fashion. But he will not advocate its use in this
way. No other presenters will discuss unlabeled
use of commercial products or products for investigational use. I will give you more registration information
later in the broadcast. During the day
of the broadcast,
Our first speaker is Dr. John Jernigan. Dr. Jernigan is an infectious disease
specialist and co-leader for the sars clinical And Infection Control Team at
cdc. Dr. Jernigan will describe sars
symptoms and clinical findings, radiographic features of the disease, and
clinical outcomes. He also will describe
the status of sars diagnosis and current information on sars transmission.
Welcome.
Thank you, Kysa. Can I have
the first graphic, please? I'd like to
begin by giving you an idea of how -- what the clinical presentation of severe
acute respiratory syndrome, or sars, is.
The best information we have, we believe that the incubation period most
commonly falls between two and ten days.
In general, the illness begins not as a respiratory disease, but as a
disease characterized by fever, chills and rigors, accompanied by headaches, myalgias,
and often malaise. We've heard from some
of our international partners that the headache, myalgias, and malaise actually
may begin a little bit before the fever, as much as 24 to 48 hours before onset
of fever. After that, respiratory symptoms
don't begin until approximately three to seven days after symptom onset. And those symptoms are most commonly dyspnea
and dry cough. This graphic shows the
most common symptoms reported by patients with sars. You can see, fever seems to be present in
nearly all patients. Cough and dyspnea are
very common. Cough is usually dry and
unproductive. Chills and rigor have been
very frequent findings amongst all the reporting sites as has myalgias and
headache. Interestingly, diarrhea has been recorded in a significant proportion
of patients, although this has varied by site, as low as 10-15 % in some
reporting centers and as high as two-thirds of the patients in others.
These are data from patients in the United States who have had
definitive diagnostic testing for the sars-associated coronavirus. All the patients represented in this slide
have met the case definition for either suspect or probable sars based upon
clinical and epidemiologic criteria. The
column on the left represents those who had laboratory evidence confirming the infection
with sars, and the column on the right represents those who have had
sars-associated coronavirus infection ruled out by various lab techniques,
including the absence of serologic response after at least 21 days following
the onset of symptoms. Overall, the two
groups are fairly similar. I will point
out that the symptom of dyspnea was present in all of the coronavirus-positive
patients. And this was higher than in
the coronavirus-negative group, a difference which approached a statistically
different difference. In addition,
diarrhea was disproportionately represented among the coronavirus-positive group. Of note, upper respiratory tract symptoms
were only present in one of our six patients and seemed to be present in the
lower proportion compared to those that were
coronavirus negative.
These are some other clinical findings that are commonly seen in
patients with sars. On physical
examination, it's common to have rales and rhonchi on pulmonary exam. And hypoxia, defined by an oxygen saturation
of less than 95% on room air, has been very commonly seen as well. Laboratory
findings include, usually, a
transaminases, increase in LDH and CPK. Actually, increases in the lactate dehydrogenase are
seen in a large majority of patients.
Again, these are data with those same clinical laboratory findings and
physical findings on our group of patients who have been tested for
coronavirus, those who have had documented infection and those who had
coronavirus infection ruled out. As you
can see, having rales or rhonci on examination, being hypoxic, having pulmonary
infiltrates has been statistically associated with coronavirus infection. From a laboratory point of view, these numbers
are small. We haven't demonstrated any statistically
significant differences; however, leukopenia, lymphopenia, low platelets, and
increased transaminases may be associated with coronavirus infection.
The radiographic features of sars include a predominance of patients
who do have pulmonary infiltrates. Ultimately,
we think at least 80% of cases will go on to develop pulmonary infiltrates at
some point in their illness although not necessarily on admission. As many as 25% to 40% of patients may present
actually with
Regarding the clinical outcome of patients with sars, these are data
from various reporting centers, including three different centers in
This table shows data on the case fatality rate that were taken off
the World Health Organization web site.
As you can see, centers in
Several of the centers have tried to identify clinical features that
are associated with severe disease. Most
of the centers have seen an association with older age, and more severe
outcome, as I've just mentioned. In
addition, underlying illness seems to be associated with more severe
disease. Some have suggested that the
lactate dehydrogenase levels may be associated with more severe illness, and
severe lymphopenia may also be associated.
One critical question that remains unanswered is precisely how long
is the period of communicability. We don’t
yet know the answer to that question, but we do have data on viral shedding in
With regard to transmission, we believe that the epidemiology
suggests that the major modes of transmission are large droplet aerosolization
and contact, either direct by direct contact with the patient, or perhaps by
indirect contact with fomites. There is
evidence that the virus can persist for some period of time after drying on
inanimate surfaces. Airborne
transmission cannot be ruled out in all cases, and in fact, there's concern
that there may be clusters of infections among health care workers who have
been involved in aerosol-generating procedures.
And in these settings in particular, we're concerned that airborne
transmission could
This graphic was shared by the Singapore Ministry of Health and is published
in the mmwr. It shows probable cases of sars reported by source of infection in
With regard to diagnosing patients who may be presenting with
possible sars, i think it's first -- it's important-- to remember to consider
other potential etiologies. We recommend
that the diagnostic workup should include a chest radiograph; blood and sputum
cultures; pulse oximetry measured on room air; testing for other viral
pathogens when appropriate, for example, influenza; and consideration should be
given to testing urinary antigens for legionallis species, and streptococcus
pneumoniae. It's important to remember
to save clinical specimens, including respiratory blood and serum specimens. Remember to save an acute sera, and make plans
for collecting a convalescent serum at least 21 days after onset of symptoms so
antibody testing for the SARS-associated coronavirus can be performed. Your local and state health departments can
assist you in how to collect the specimens and where to send the specimens for
further testing.
With regard to treatment of patients with sars, unfortunately we
have a
Potential therapies that require further investigation include those
on the slide. Ribavirin with or without corticosteroids have been used around
the world. There are anecdotal reports
of success; however, we think that these data are difficult to interpret and
that we need more information from controlled clinical trials to determine the
benefit of this particular therapy.
Ribavirin has been tested in vitro
in several laboratories and has been not found to have any demonstrable
biological activity against this particular virus. However, it's possible that there may be
other nonvirologic effects of ribavirin, including potential immunomodulatory effects
that could conceivably have benefit.
This again needs to be studied in controlled trials. We're working collaboratively with the NIH
and others to test large numbers of antiviral agents to try to come up with
compounds that may be of benefit.
There is an existing hypothesis that some of the pathogenesis may
involve an immune response to the infection, and therefore immunomodulatory agents
have been proposed as possibly being beneficial. Corticosteroids have been used
widely, interferons have been given consideration, and there are others that
are under consideration. For the moment, again to summarize, we don't know the
most effective therapeutic options for this infection.
With regard to infection control, we think that early recognition
and isolation of the patient is key.
Clinicians should maintain heightened suspicion for patients who might
present to their hospitals or offices who might be at risk for sars, and triage
procedures should be adjusted accordingly to be able to pick up these people
early and isolate them early on after their presentation. It's important to remember that transmission
may occur during the very earliest symptomatic phases, potentially before both fever
and respiratory symptoms develop, that is, before they actually might meet the
case definition for sars.
THE BASICS OF INFECTION CONTROL INCLUDE
CLEAN HAND HYGIENE, contact precautions, EYE PROTECTION, AND ENVIRONMENTAL CLEANING
AS WELL AS protection against AIRBORNE PRECAUTIONS. I THINK IT'S IMPORTANT TO REMEMBER
THAT THIS IS AN AREA WHERE OUR KNOWLEDGE BASE IS RAPIDLY EXPANDING, AND WE'LL
DO OUR BEST TO KEEP CLINICIANS INFORMED AS WE GET MORE INFORMATION.
>> Kysa: DR. JERNIGAN, WE certainly
APPRECIATE YOUR EXPERTISE. THANK YOU.
LET'S TURN OUR ATTENTION TO DR. DEAN
ERDMAN. DEAN ERDMAN IS A DOCTOR OF PUBLIC HEALTH AND ACTING CHIEF OF THE
RESPIRATORY AND VIRAL DISEASE SECTION AT CDC. DR. ERDMAN WILL DISCUSS THE
STATUS OF LABORATORY DIAGNOSIS OF SARS INFECTION, INCLUDING CHARACTERISTICS OF
THE SARS CORONAVIRUS, THE TYPE AND TIMING OF SPECIMEN COLLECTION, AND TYPES OF
ASSAYS. WELCOME.
>> THANK YOU, KYSA. MAY I HAVE THE FIRST SLIDE, PLEASE? BEFORE BEGINNING MY PRESENTATION ON THE
LABORATORY DIAGNOSIS OF SARS, THERE IS ONE KEY POINT
OF WHICH WE NEED TO REMIND OURSELVES. SARS
IS EXPLICITLY A CLINICAL
AND EPIDEMIOLOGIC diagnosis. Therefore, it is likely that MANY SARS CASES
AS DEFINED ARE NOT ACTUALLY INFECTED WITH THE SARS CORONAVIRUS, AND THIS has
VERY IMPORTANT IMPLICATIONS FOR THE INTERPRETATION OF LABORATORY RESULTS.
NOW, TO ESTABLISH RELIABLE LABORATORY
EVIDENCE OF SARS INFECTIONS, WE NEED TO CONSIDER THREE IMPORTANT ISSUES: 1. THE
TYPE OF SPECIMEN TO COLLECT,
2. THE TIMING OF SPECIMEN COLLECTION, AND
3. THE SELECTION OF
laboratory ASSAY TO DETECT INFECTION. IN GENERAL, MOST OF THESE ISSUES
WERE ADDRESSED IN THE WEEKS FOLLOWING THE
RECOGNITION OF THE
OUTBREAK. HOWEVER, THERE ARE STILL MANY SPECIFIC
DETAILS FOR WHICH WE DO
NOT AS YET HAVE AN ANSWER. THERE IS NOW A
STRONG ASSOCIATION BETWEEN THE NEWLY
IDENTIFIED CORONAVIRUS AND SARS BASED ON
MULTIPLE LINES OF EVIDENCE.
BOTH BIOLOGICAL AND SEROLOGICAL
identification of the novel CORONAVIRUS HAVE BEEN MADE IN SARS CASES AT CDC AND
in MULTIPLE LABORATORIES AROUND THE
WORLD. IN CONTRAST, NON-SARS PATIENTS HAVE
NO SEROLOGIC EVIDENCE of past infection with this virus, AS
DEMONSTRATED IN SEPARATE LABORATORIES,
BOTH AT CDC AND IN
THE VIRUS HAS BEEN IDENTIFIED BY CULTURE,
IN PCR, FROM LOWER
RESPIRATORY TRACT SPECIMENS, and LUNG,
LINKING IT MORE DIRECTLY
TO THE SITE OF PATHOLOGY. ALSO, GENETIC SEQUENCES FROM
MULTIPLE VIRUS ISOLATES FROM DIFFERENT
GEOGRAPHIC LOCATIONS
ARE ESSENTIALLY IDENTICAL, SUGGESTING A
POINT SOURCE OUTBREAK. And RECENT STUDIES IN THE
VIRUS INFECTION OF TISSUE OR FROM
SUBSEQUENT IMMUNE RESPONSE? AND WHAT IS
THE TRUE RATE Of POSITIVITY IN SARS CASES?
THE ETIOLOGIC AGENT OF SARS IS SHOWN IN
THIS ELECTROnMICROGRAPH.
NOTE THE CHARACTERISTIC FRINGE OF
PROTEINS ON THE VIRUS SURFACE, referred to as peptoburrs, WHICH ARE VERY
CHARACTERISTIC OF THE CORONAVIRUSES.
CORONAVIRUSES RESIDE withIN THE ORDER OF
THE VERALES, Family coronaviridae.
WITHIN THIS FAMILY, THE GENUS coronovirus
has BEEN classically subdivided INTO THREE MAJOR antigenic GROUPS, ONE, TWO,
AND THREE. ALL OF THE KNOWN HUMAN AND
ANIMAL CORONAVIRUSES CAN BE CLASSIFIED
WITHIN THESE THREE GROUPS. THE TWO HUMAN CORONAVIRUSES, 229-E, AND OC-43,
RESIDE IN GROUPS 1 AND 2 RESPECTIVELY. THE
KNOWN HUMAN CORONAVIRUSES HAVE BEEN LINKED PRIMARILY TO MILD UPPER RESPIRATORY
ILLNESSES and like RHINOVIRUSES, are a major cause of THE COMMON COLD.
THE animal CORONAVIRUSES IN CONTRAST have representatives IN ALL
THREE
GROUPS, AND THE SPECTRUM OF DISEASE
CAUSED BY THE ANIMAL
CORONAVIRUSES IS quite BROAD, both in
terms of major organ systems affected and SEVERITY OF DISEASE.
THE COMPLETE GENOME of the SARS
coronavirus HAS NOW BEEN SEQUENCED both at CDC and MULTIPLE other LABORATORIES.
THE GENETIC ORGANIZATION OF THE SARS
CORONAVIRUS IS illustrated IN
THIS SLIDE, SHOWING THE
PREDICTED OPEN
OR GENES, AND messenger RNA TRANSCRIPTS.
THIS SEQUENCE DATA HELPED US TO
DETERMINE, ONE, THAT THE SARS
CORONAVIRUS IS ENTIRELY NEW, NOT
a recombinant or PREVIOUSLY KNOWN
VIRUS, AND
TWO, IT HELPS
DIAGNOSTIC ASSAYS THAT CAN
DISTINGUISH SARS FROM ALL other
KNOWN CORONAVIRUSES.
NOW, SUCCESSFUL LABORATORY
DIAGNOSIS OF SARS INFECTION
REQUIRES A THOROUGH
UNDERSTANDING OF THE TYPE AND
TIMING OF SPECIMEN COLLECTION
AND THE TYPE OF ASSAYS TO APPLY WITH
A FULL UNDERSTANDING OF THE
STRENGTH AND WEAKNESSES OF THOSE
ASSAYS. AS MORE CLINICAL AND
EPIDEMIOLOGICAL DATA HAVE BECOME
AVAILABLE, WE HAVE BEEN ABLE TO
REFINE OUR CHOICE OF SPECIMENS
TO COLLECT. ASSAYS INTRODUCED AT THE
BEGINNING OF THE OUTBREAK ARE
RAPIDLY
BEING REPLACED WITH
ASSAYS
WITH IMPROVED SENSITIVITY
AND
SPECIFICITY. HOWEVER, THE BOTTOM LINE IS THAT
AT THIS
EARLY STAGE OF THE
OUTBREAK,
WE NEED MORE
INFORMATION.
NOW,
LABORATORY ASSAYS FOR THE
SARS
CORONAVIRUS ARE BASED
EITHER ON detection
OF THE VIRUS
OR VIRUS
PRODUCTS, OR detection
OF AN
ANTIBODY RESPONSE to viral infection.
VIRUS
ISOLATION in virocells and
ELECTROnMICROSCOPy
PLAYED A
CRUCIAL
ROLE IN THE EARLY
IDENTIFICATION OF THE SARS
CORONAVIRUS. And THE CAPACITY TO GROW THE
VIRUS to
high titer IN THESE CELLS ALLOWED
RAPID
DEVELOPMENT of
SEROLOGICAL
ASSAYS using whole virus antigen preparations.
However,
both electron microscopy and CULTURE LACK SENSITIVITY FOR
ROUTINE
DIAGNOSIS, AND CULTURE
POSES A
PARTICULAR HAZARD
OUTSIDE
BIOSAFETY LEVEL 3
FACILITIES.
DETECTION OF VIRAL ANTIGENS IS A
POSSIBILITY
AND USEFUL FOR immunohistochemistry
WITH
TISSUES.
BUT WE
SUSPECT THAT ASSAYS LIKE
IFA AND ELISA
for antigen detection IN RESPIRATORY
SECRETIONS
AND OTHER SPECIMENS
WOULD BE
LESS SENSITIVE THAN
DESIRABLE
FOR ROUTINE USE.
THE KEY
ASSAY FOR US AND OTHERS
HAS BEEN
PCR. OUR PCR ASSAYS HAVE EVOLVED FROM
A SINGLE genome
TARGET USING MORE
CONVENTIONAL
AMPLIFICATION and product detection
METHODS TO
REALTIME Taqman PCR FORMAT USING
MULTIPLE genome
TARGETS. WE ARE ALSO DEVELOPING MORE
EXTENSIVE
EXPERIENCE WITH THIS
ASSAY OVER
A
CLINICAL
SAMPLES.
CDC HAS
ALSO developed SEROLOGICAL ASSAYS based on IFA and Elisa THAT ARE
BEING USED
FOR ROUTINE ANTIBODY
SCREENING AS
WELL AS PLAQUE
NEUTRALIZATION
ASSAYS USED FOR
SPECIFIC
STUDIES.
OUR
REALTIME TAqMAN RT-PCR assay IS THE CORE
TEST on WHICH
WE currently RELY FOR SPECIMEN
SCREENING.
MOST OF YOU, I AM SURE, ARE
FAMILIAR
WITH THIS METHODOLOGY,
BUT
BRIEFLY, WITH TAqMAN, ONE
PERFORMS a
CONVENTIONAL PCR
AMPLIFICATION
IN THE PRESENCE OF
A PROBE
THAT IS SPECIFIC to THE
AMPLIFIED
PRODUCT. AS AMPLIFICATION PROCEEDS, AND
THE
PRODUCT GENERATED, THE PROBE
hybridizes
TO THE PRODUCT AND is
IMMEDIATELY
DEGRADED by the advancing Taq polymerase, WHICH
POSSESSES
ENDONUCLEase
ACTIVITY. SPECIALIZED
LABELS ATTACHED TO
THE PROBE
RELEASE LIGHT WHEN THE
PROBE IS
DEGRADED. LIGHT EMISSION INCREASES
PROPORTIONALLY
WITH PRODUCT
AMPLIFICATION.
WITH A SPECIALLY EQUIPPED
THERMOCYCLER,
THIS light emission CAN BE
MEASURED
DURING THE
AMPLIFICATION
REACTION, HENCE,
REALTIME
PCR.
THEse DATA
THAT YOU SEE ON the
SLIDE ARE
ACTUAL RESULTS
OBTAINED
WITH OUR SARS REALTIME
PCR ASSAY,
SHOWING POSITIVE
REACTIONS
OBTAINED IN SEVERAL SAMPLES. FOR EACH SPECIMEN, WE AMPLIFY
THREE
DIFFERENT TARGETS IN TWO SEPARATE GENES, AND INCLUDE
HOUSEKEEPING
GENE control to ensure RNA INTEGRITY.
ALTHOUGH
OUR REALTIME PCR HAS BEEN EXTENSIVELY EVALUATED FOR
SENSITIVITY
AND SPECIFICITY USING RNA EXTRACTS FROM THE SARS
CORONAVIRUS
AND OTHER RESPIRATORY PATHOGENS, WE ARE STILL GATHERING DATA TO ASSESS ITS
PERFORMANCE WITH CLINICAL SAMPLES. NEVERTHELESS, WE CAN DRAW SOME
PRELIMINARY
CONCLUSIONS FROM DATA THAT WE HAVE OBTAINED THUS FAR. RESPIRATORY SPECIMENS ARE
STILL THE SPECIMENS OF CHOICE FOR DETECTION OF SARS CORONAVIRUS by PCR. UPPER RESPIRATORY TRACT SPECIMENS ARE
POSITIVE IN APPROXIMATELY 50% OF ACUTE phase SPECIMENS FROM TRUE SARS-POSITIVE
CASES. AMONG THE RANGE OF POSSIBLE
RESPIRATORY
SPECIMENS, IT APPEARS THAT SPUTUM and BALs MAY OFFER
HIGHER
RATES OF POSITIVITY. Data from other
laboratories suggest that STOOL MAY ALSO BE A PROMISING
SPECIMEN,
WITH REPORTS SUGGESTING THAT STOOL SPECIMENS OFFER HIGHER SENSITIVITIES LATER IN
ILLNESS. THERE STILL REMAINS A QUESTION
REGARDING
THE VALUE OF OTHER CLINICAL SPECIMENS, HOWEVER.
NOW, ONCE
YOU OBTAIN YOUR PCR RESULT, HOW DO YOU INTERPRET IT?
A NEGATIVE
RESULT DOES NOT RULE OUT SARS CORONAVIRUS INFECTION,
WHICH MAY
BE BELOW THE LEVEL OF DETECTION DUE TO INADEQUATE SPECIMEN COLLECTION OR PCR INHIBITION.
And a POSITIVE PCR RESULT DOES NOT GUARANTEE INFECTION as contamination of the
assay with the PCR product can BE DIFFICULT TO
DISTINGUISH
FROM A TRUE POSITIVE RESULT. BUT ONE TRUTH REMAINS, TO BE
USEFUL,
PCR MUST BE APPLIED DURING THE ACUTE PHASE OF ILLNESS.
AS
MENTIONED EARLIER, CDC AND OTHERS HAVE DEVEloped SEROLOGICAL TESTS BASED ON
IMMUNOFLUORESCENCE
and ELISA FOR DETECTION OF SARS CORONAVIRUS-specific IGG ANTIBODIES. THESE ASSAYS REPRESENT THE MOST DEFINITIVE
TESTS FOR SARS
DIAGNOSIS ALTHOUGH
RESULTS ARE UNAVOIDABLY DELAYED.
ASSAY
DESIGN FOLLOWS THE CONVENTIONAL INDIRECT ASSAY
FORMAT, AS
ILLUSTRATED.
A
DETERGENT EXTRACT OF CULTURED
VIRAL
LYSATE IS coated onto GLASS SLIDES or microtiter plates.
THIS IS
FOLLOWED BY a DILUTION
OF THE
PATIENT'S SERUM.
SPECIFIC
IGG antibodies present in the serum BIND TO THE viral ANTIGEN
WHICH are in
TURN DETECTED WITH
Antihuman
IGG CONJUGATE, AND THE
RESULTING flouresence
are COLOR MEASURED.
THE DELAY
IN PROVIDING WIDER
DISTRIBUTION
OF THIS ASSAY HAS
BEEN THE
LACK OF POSITIVE
CONTROL
SERA. WE HAVE RECENTLY ACQUIRED PLASMA
UNITS FROM
CONVALESCENT SARS
CASES,
WHICH WILL BE USED TO MAKE
A POSITIVE
CONTROL IN QUANTITY.
IN
DEVELOPMENT, are recombinant PROTEINS TO
REPLACE
THE WHOLE VIRUS antigen and
monoclonal
antibodies for USE IN DEVELOPMENT OF
CAPTURE
IGM ASSAYS THAT WILL
permit serologic
DIAGNOSIS EARLIER IN THE
COURSE OF
INFECTION.
AGAIN, WE
ARE STILL ACQUIRING
DATA THAT
WILL HELP US ASSESS
THE
PERFORMANCE OF OUR SEROLOGIC TESTS.
WHAT SEEMS
CLEAR IS THAT THERE
IS VERY
LOW OR NO ANTIBODIES IN
PERSONS
WITHOUT ACUTE SARS.
IN PERSONS
WITH DEFINITIVE SARS coronavirus
INFECTION,
the acute phASE
SERUM MAY
HAVE DETECTABLE
ANTIBODy as
early as SIX DAYS after onset of illness.
AND convalescent
sera SHOULD BE POSITIVE by 21
DAYS.
INTERPRETATION
OF SEROLOGICAL
TESTS IS more
STRAIGHTFORWARD than for PCR.
TODAY WE
CAN ASSUME FROM A
SINGLE
POSITIVE SERUM SPECIMEN
THAT THE
PATIENT HAS ACUTE SARS
CORONAVIRUS
INFECTION.
LATER,
WHEN THE NUMBER OF
POSITIVE
PERSONS IN THE
POPULATION
GOES UP, WE WILL NEED
TO
DEMONSTRATE RISES IN IGG
ANTIBODIES
OR USE IGM detection TO
DIAGNOSE
ACUTE INFECTION.
And THERE
WILL ALWAYS BE those
PATIENTS
THAT PRODUCE A poor
IMMUNOLOGIC
RESULT. IN THESE CASES AN ADDITIONAL
SPECIMEN
LATER THAN 21 DAYS MAY
BE
REQUIRED TO RULE OUT
INFECTION.
I HAVE
ALREADY MENTIONED SOME OF
THE OTHER
TESTS FOR SARS
CORONAVIRUS
INFECTION, INCLUDING
TISSUE
CULTURE, ISOLATION,
ELECTROMICROSCOPY,
immunologic and in situ studies of tissue samples AND
ANTIGEN
DETECTION assays and their relative strengths and weaknesses.
I SHOULD
ALSO MENTION THAT
DURING THE
LAST SEVERAL WEEKS,
WE HAVE
BEEN CONTACTED BY
NUMEROUS
COMPANIES OFFERING NEW
AND
POTENTIALLY USEFUL ASSAYS
FOR THE
SARS CORONAVIRUS,
SOME OF
WHICH MAY BECOME
COMMERCIALLY
AVAILABLE IN THE
NEAR
FUTURE.
IN
CONCLUSION, AND TO REITERATE
WHAT WAS
SAID EARLIER, SARS
IS A
CLINICAL AND EPIDEMIOLOGIC
DIAGNOSIS,
with all that
ENTAILS
FOR the interpretation of LABORATORY RESULTS.
THE
LABORATORY CAN DIAGNOSE SARS
CORONAVIRUS
INFECTION DURING THE
ACUTE
ILLNESS BUT CANNOT RULE
OUT
INFECTION UNTIL THE
CONVALESCENT
PHASE WHEN SERA
CONVERSION
CAN BE ASSESSED.
FINALLY,
DUAL INFECTIONS WITH
OTHER
VIRUSES CAN OCCUR IN
PATIENTS
WITH SARS CORONAVIRUS
INFECTION;
and THEREFORE, DETECTION
OF OTHER
VIRUSES IN SARS CASES
MUST BE
INTERPRETED WITH CARE.
THAT
CONCLUDES MY PRESENTATION.
THANK YOU
VERY MUCH.
>>
AND THANK YOU, DR. ERDMAN.
NOW WE
WANT TO TURN OUR
ATTENTION
TO OUR NEXT PRESENTER
WHO IS MS.
LINDA CHIARELLO.
MS.
CHIARELLO IS AN
EPIDEMIOLOGIST
AND INFECTION
CONTROL SPECIALIST
IN THE DIVISION OF HEALTHCARE
QUALITY PROMOTION AT CDC.
SHE WILL REVIEW INFECTION
CONTROL GUIDANCE FOR HEALTHCARE
PRACTITIONERS, SARS PATIENTS,
AND PERSONS EXPOSED TO SARS.
MS. CHIARELLO.
>> THANK YOU, KYSA.
MAY I HAVE MY FIRST GRAPHIC,
PLEASE.
DURING
THE PREVIOUS
TELECONFERENCE, TWO AREAS WERE
DISCUSSED THAT ARE CRITICAL TO
AN UNDERSTANDING OF INFECTION
CONTROL. THEY ARE THE KEY OBJECTIVES FOR
PREVENTING TRANSMISSION THAT
DR. GERBERDING MENTIONED
EARLIER: EARLY detection, containment of
infection, PROTECTION OF
HEALTH CARE PERSONNEL AND THE
ENVIRONMENT OF CARE, AND HAND
HYGIENE, THE CORNERSTONE OF
INFECTION PREVENTION.
ALSO DISCUSSED WERE THE
STRATEGIES OR INTERVENTIONS USED
TO MEET THESE OBJECTIVES THAT
ARE BRIEFLY OUTLINED HERE AND
ARE REFLECTED IN THE INFECTION
CONTROL GUIDANCE ON THE CDC SARS
WEB SITE.
TODAY,
I WILL FOCUS ON AREAS
THAT HAVE RECENTLY BEEN
ADDRESSED AND UPDATED IN TERMS
OF INFECTION CONTROL GUIDANCE
FOR HEALTH CARE FACILITIES,
NAMELY, ISSUES AROUND
RESPIRATORY PROTECTION,
MANAGEMENT OF EXPOSED HEALTH
CARE PERSONNEL, AND
ENVIRONMENTAL CLEANING AND
DISINFECTION. I WILL ALSO TALK ABOUT THE
MANAGEMENT OF PERSONS IN THE
COMMUNITY WHO HAVE BEEN EXPOSED
TO SARS, WHICH TIES INTO THE
FIRST TWO OBJECTIVES OF EARLY
DETECTION AND CONTAINMENT OF
INFECTION.
TRANSMISSION
OF SARS DURING
AEROSOL GENERATING PROCEDURES
APPEARS TO BE VERY EFFICIENT.
AS DR. JERNIGAN MENTIONED,
CLUSTERS OF INFECTION AMONG
PERSONNEL WHO WERE DIRECTLY
INVOLVED IN INTUBATION,
SUCTIONING, AND USE OF NEBULIZERS in SARS
patients
HAVE BEEN DETECTED IN
TRANSMISSIONS ARE UNCLEAR.
ONE POSSIBILITY IS THAT PATIENT
infectivity MIGHT BE HIGHER
WITH the onset of respiratory FAILURE.
IT ALSO IS NOT KNOWN WHETHER
TRANSMISSION IS FROM A HIGH
BIOBURDEN OF RESPIRATORY
DROPLETS, HEAVY CONTAMINATION OF
THE ENVIRONMENT THROUGH AIRBORNE
SPREAD, OR A COMBINATION OF ALL
THREE.
IN SOME CASES, LACK OF
PROTECTIVE ATTIRE APPEARED TO BE
A FACTOR IN TRANSMISSION.
HOWEVER, IN OTHER EPISODES,
TRANSMISSION OCCURRED DESPITE
THE USE OF PROTECTIVE EQUIPMENT.
WHETHER THIS REPRESENTS A TRUE
FAILURE OF THE EQUIPMENT OR
IMPROPER USE OF THE EQUIPMENT IS
NOT KNOWN. THESE TRANSMISSIONS ARE AN
OBVIOUS CONCERN FOR INFECTION
CONTROL AND HAVE LED CDC TO
ISSUE RECOMMENDATIONS TO LIMIT
cough-INDUCING PROCEDURES TO
THOSE THAT ARE MEDICALLY
NECESSARY, TO AVOID USE OF
NON-INVASIVE VENTILATION, SUCH
AS C-PAP AND BI-PAP, AND TO USE
CLOSED SUCTIONING DEVICES FOR
MECHANICAL VENTILATION AND
FILTERS ON EXHALATION VALVE
PORTS. IN ADDITION, IT IS PRUDENT TO
LIMIT THE NUMBER OF PERSONNEL IN
THE ROOM TO THOSE WHO ARE
ESSENTIAL FOR PERFORMING THE
PROCEDURES. AND PERSONNEL INVOLVED IN THE
PROCEDURE SHOULD WEAR THE
APPROPRIATE PROTECTIVE EQUIPMENT
INCLUDING GOWN AND GLOVES,
SEALED EYE PROTECTION, AND BY THAT WE
MEAN SOMETHING
THAT FITS OVER THE EYES SUCH AS
GOGGLES RATHER THAN A FACE
SHIELD, AND A RESPIRATORY PROTECTION
DEVICE.
CDC
IS IN THE PROCESS OF
UPDATING guidance
ON USE OF
RESPIRATORS FOR AEROSOL
GENERATING PROCEDURES.
UNTIL THESE RECOMMENDATIONS ARE
FINALIZED, WE WANT TO ALERT
HEALTH CARE FACILITIES ABOUT
THIS CONCERN.
ANECDOTAL
INFORMATION FROM
HEALTH CARE WORKERS WHO BECAME
RESPIRATOR THEY WERE USING DID
NOT fit WELL. THEREFORE, REASSESSMENT OF
RESPIRATOR FIT AMONG PERSONNEL
WHO MAY BE INVOLVED IN THE
INTUBATION OF SARS PATIENTS
SHOULD BE CONSIDERED. CONSIDERATION ALSO
SHOULD BE
GIVEN TO USING RESPIRATORS WITH
A TIGHTER SEAL, including N-99 and N-100
devicesOR USE OF HALF
OR FULL-FACE elastomeric DEVICES, OR POWERED
AIR PURIFYING RESPIRATORS or PAPRs.
IF
REUSABLE DEVICES ARE
CONSIDERED, PROCEDURES FOR
CAREFUL CLEANING AND
DISINFECTION AFTER USE ARE
NECESSARY TO PREVENT THEM FROM
BECOMING A fomite FOR
TRANSMISSION.
ANOTHER
AREA WHERE CDC HAS
PROVIDED NEW INTERIM GUIDANCE
CONCERNS SURVEILLANCE FOR AND
MANAGEMENT OF SARS EXPOSURES IN
HEALTH CARE SETTINGS. SUGGESTED
SURVEILLANCE
ACTIVITIES INCLUDE DEVELOPING A
LOG OF PERSONNEL WHO ENTER THE
ROOM OF PATIENTS WITH SARS.
IF THERE'S SUBSEQUENT
TRANSMISSION, SUCH A LOG WILL
HELP FACILITIES IDENTIFY OTHER
PERSONNEL WHO MAY HAVE BEEN
EXPOSED. OTHER SURVEILLANCE ACTIVITIES
MAY INCLUDE ENCOURAGING
PERSONNEL TO REPORT UNPROTECTED
EXPOSURES AND MONITORING
EMPLOYEE ABSENTEEISM FOR
SARS-LIKE ILLNESSES SUCH AS
ATYPICAL PNEUMONIA.
AS
DR. JERNIGAN MENTIONED
EARLIER, AT THIS TIME THERE IS
NO EVIDENCE FOR TRANSMISSION OF
SARS from PERSONs who have NO SYMPTOMS
OF THE DISEASE. HOWEVER, TRANSMISSION OF
SARS IN
HEALTH CARE SETTINGS HAS
SOMETIMES INVOLVED HEALTH CARE
PERSONNEL WHO WORKED WITH EARLY
SYMPTOMS. IT ALSO HAS INVOLVED HEALTH
CARE
PERSONNEL INVOLVED IN THE
AEROSOL GENERATING PROCEDURES,
AS I JUST DISCUSSED. THEREFORE, CDC IS
RECOMMENDING
THAT ACTIVE SURVEILLANCE BE
PERFORMED DAILY ON ANY HEALTH
CARE WORKER WHO HAS AN
UNPROTECTED EXPOSURE TO A SARS
PATIENT. THIS INCLUDES MEASURING THE
WORKER'S TEMPERATURE AND
ASSESSING FOR RESPIRATORY
SYMPTOMS BEFORE BEGINNING WORK.
IN ADDITION, CDC RECOMMENDS A
TEN-DAY EXCLUSION FROM DUTY FOR
HEALTH CARE WORKERS WHO HAVE AN
UNPROTECTED EXPOSURE DURING AN
AEROSOL GENERATING PROCEDURE,
INCLUDING AEROSOLIZED medication TREATMENTs
DIAGNOSTIC SPUTUM INDUCTION,
BRONCHOSCOPY, endotracheal intubation, AIRWAY SUCTIONing,
AND CLOSE FACIAL CONTACT DURING
A COUGHING PAROXYSM.
HEALTH CARE WORKERS WHO
ARE
EXCLUDED FROM DUTIES SHOULD
LIMIT INTERACTIONS OUTSIDE THE
HOME AND SHOULD NOT GO TO WORK,
SCHOOL, CHURCH, OR OTHER PUBLIC
AREAS.
ANOTHER ISSUE WE RECENTLY
ADDRESSED CONCERNS THE LIMITED
SUPPLY OF N-95 RESPIRATORS IN
THE UNITED STATES, AND IN OTHER
COUNTRIES AND WHETHER RESPIRATORS SHOULD BE
REUSED AS IT DONE WITH
TUBERCULOSIS. THE CONCERN WITH SARS IS THE
POTENTIAL FOR CONTAMINATION
DURING PATIENT CARE EITHER FROM RESPIRATORY DROPLETS
DEPOSITED DIRECTLY ON THE FRONT
OF THE RESPIRATOR, OR FROM
TOUCHED CONTAMINATION WITH
GLOVED OR UNGLOVED HANDS IN THE
COURSE OF HANDLING THE
RESPIRATOR. FOR THIS REASON, CDC PREFERS
THAT RESPIRATORS BE DISPOSED
AFTER A SINGLE USE. HEALTH CARE FACILITIES SHOULD
TAKE STEPS TO CONSERVE LIMITED
SUPPLIES BY ASSESSING FOR
UNNECESSARY RESPIRATOR USE IN
THEIR FACILITIES.
IN THE UPDATED
GUIDANCE, CDC
PRESENTS A HIERARCHY of OPTIONS
for SITUATIONS WHERE DISPOSAL
AFTER SINGLE USE IS NOT
FEASIBLE. THESE INCLUDE USING LEVEL N, P
AND R RESPIRATORS FIRST.
AND IF A CHOICE MUST BE MADE
BETWEEN REUSING RESPIRATORS OR
GOING TO USE OF A SURGICAL MASK,
REUSE IS THE PREFERRED OPTION.
PROCEDURES FOR CAREFUL HANDLING
THAT REINFORCE HAND HYGIENE
AFTER CONTACT WITH A
CONTAMINATED RESPIRATOR SHOULD
BE
THEN A SURGICAL MASK SHOULD BE
USED.
THE ENVIRONMENT AROUND
A PATIENT
WITH SARS IS THOUGHT TO BE
HEAVILY CONTAMINATED AND MAY BE
A KEY FACTOR IN TRANSMISSION.
THEREFORE, CDC HAS PROVIDED NEW
GUIDANCE ON CLEANING AND
DISINFECTION FOR SARS.
THIS GUIDANCE REFLECTS THE SAME
PRINCIPLES USED FOR PREVENTING
TRANSMISSION OF OTHER INFECTIOUS
AGENTS IN THE ENVIRONMENT.
BUT IT AIMS TO REINFORCE THE
IMPORTANCE OF CLEANING AND
DISINFECTION AND TO ENCOURAGE
TRAINING OF PERSONNEL AND
MONITORING OF THIS PROCESS IN
THE ROOMS WHERE SARS PATIENTS
ARE HOUSED.
CLEANING PROCEDURES IN
INPATIENT
AREAS SHOULD FOCUS ON DAILY
CLEANING OF SURFACES THAT ARE
TOUCHED FREQUENTLY, SUCH AS BED
RAILS, OVER BED TABLES, DOOR
KNOBS AND LABORATORY surfaces.
AND A MORE THOROUGH CLEANING
SHOULD BE PERFORMED AT THE TIME
OF TRANSFER OR DISCHARGE. HOWEVER, THIS DOES NOT NEED TO
INCLUDE AIR FOGGING OR ROUTINE
CLEANING OF WALLS OR CEILINGS
UNLESS THESE AREAS ARE VISIBLY
SOILED.
CDC RECOMMENDS USING AN
EPA
REGISTERED HOSPITAL DETERGENT
DISINFECTANT.
SINCE IT IS LIKELY THAT MOST
HEALTH CARE FACILITIES IN THE
UNITED STATES CURRENTLY USE SUCH
AGENTS, THIS WILL NOT REQUIRE
ANY CHANGE FROM CURRENT
PROCEDURES.
I WILL NOW MOVE FROM
DISCUSSING
INFECTION CONTROL IN HEALTH CARE
FACILITIES TO THE MANAGEMENT OF
EXPOSED AND SYMPTOMATIC PERSONS
WHO CONTACT CLINICIANS FOR
ADVICE.
THE INFECTION CONTROL
PRINCIPLES
USED TO PREVENT TRANSMISSION OF
SARS IN THE HOME MIRROR THOSE
APPLIED IN HEALTH CARE SETTINGS.
THESE INCLUDE MONITORING EXPOSED
PERSONS IN THE HOME TO DETECT
EARLY ONSET OF SYMPTOMS,
CONTAINING THE INFECTION IN
SYMPTOMATIC INDIVIDUALS,
PROTECTING PERSONS IN THE
HOUSEHOLD FROM SUBSEQUENT
EXPOSURE, AND LIMITING
CONTAMINATION OF THE HOME
ENVIRONMENT WITH THE SARS VIRUS.
GUIDANCE ON THE MANAGEMENT OF
SARS IS BASED ON PRELIMINARY
INFORMATION ABOUT THE INCUBATION
PERIOD AND PERIOD OF infectivity AND WHETHER SOMEONE
has or MIGHT HAVE SARS or HAS ONLY BEEN
EXPOSED TO SARS.
THERE ARE THREE TIME
PERIODS TO
KEEP IN MIND. THE FIRST IS TEN DAYS AFTER THE
LAST EXPOSURE TO SARS, AND
DEFINES THE
MONITORING FOR INFECTION.
THIS IS BELIEVED TO BE THE
MAXIMUM INCUBATION PERIOD DURING
WHICH SYMPTOMS OF SARS SHOULD
DEVELOP FOLLOWING THE EXPOSURE.
THE SECOND IS THE 72-HOUR RULE.
THIS IS A RECOMMENDED
WAIT-AND-SEE PERIOD FOR
DETERMINING WHAT TO DO WITH AN
EXPOSED PERSON WHO HAS ONE, BUT
NOT BOTH, OF THE SYMPTOMS OF
SARS. AND THE THIRD IS THE TEN-DAY
RULE USED TO DEFINE WHEN A
PERSON WHO HAS SARS IS NO LONGER
INFECTIOUS AND CAN RETURN TO
THE COMMUNITY. AND THIS IS BASED ON RESOLUTION
OF FEVER AND IMPROVEMENT OF
RESPIRATORY SYMPTOMS.
AND
THESE ARE THE
RECOMMENDATIONS FOR PERSONS
EXPOSED TO SARS.
For THOSE WHO HAVE BEEN EXPOSED TO A
PERSON WITH SARS, OR TRAVELED IN
A GEOGRAPHIC AREA AFFECTED BY
SARS, SUCH AS
KONG, WE RECOMMEND NO CHANGE IN
DAILY ACTIVITIES. HOWEVER, THESE
INDIVIDUALS
SHOULD MONITOR THEMSELVES FOR
DEVELOPMENT OF RESPIRATORY
SYMPTOMS OR FEVER, INCLUDING
MEASURING THEIR TEMPERATURE
TWICE DAILY IN THE MORNING AND
EVENING. IF NO SYMPTOMS DEVELOP,
MONITORING MAY END TEN DAYS
AFTER THE LAST EXPOSURE.
HOWEVER, IF DURING THIS TIME
FEVER OR RESPIRATORY SYMPTOMS
DEVELOP, THE HEALTH CARE
PROVIDER SHOULD BE NOTIFIED AND
SHOULD CONSIDER WHETHER TO
EVALUATE THE PATIENT IMMEDIATELY
OR WAIT TO SEE IF THEY PROGRESS
TO SARS. DURING THIS TIME, THE PATIENT
SHOULD BE ADVISED TO BEHAVE AS
IF HE OR SHE DOES HAVE SARS, AND
LIMIT ACTIVITIES OUTSIDE THE
HOME. AT THE END OF 72 HOURS, THE
PATIENT'S SYMPTOMS SHOULD BE
ASSESSED.
THIS
ALGORITHM IS INCLUDED IN
OUR GUIDANCE ABOUT THE
MANAGEMENT OF PERSONS WITH
SARS-LIKE SYMPTOMS. AS YOU CAN SEE, IN
THE MIDDLE
BOX, FOR THOSE PERSONS WHO ARE
IN THE 72-HOUR OBSERVATION
PERIOD, THERE ARE THREE POSSIBLE
OUTCOMES. ONE IS THAT THE SYMPTOM HAS
RESOLVED, OR SUBSTANTIALLY
IMPROVED, IN WHICH CASE SARS IS
UNLIKELY. THESE INDIVIDUALS MAY RETURN TO
DAILY ACTIVITIES BUT SHOULD
CONTINUE TO SELF-MONITOR FOR THE
FULL TEN DAYS FOLLOWING THEIR
LAST EXPOSURE. ANOTHER IS THAT THERE IS
PROGRESSION OF DISEASE THAT
MEETS THE CASE DEFINITION FOR
SARS, IN WHICH CASE, CLINICAL
EVALUATION FOR SARS SHOULD BE
PERFORMED.
IF
HOSPITALIZATION IS NOT
REQUIRED, THE PATIENT SHOULD
FOLLOW THE HOME INFECTION
CONTROL RECOMMENDATIONS FOR SARS
PATIENTS THAT I WILL DISCUSS
SHORTLY.
HOWEVER,
THERE WILL BE A GROUP
OF PATIENTS WHO ARE STILL
SYMPTOMATIC AFTER 72 HOURS
BUT DO NOT MEET THE CASE
DEFINITION. IN THIS SITUATION, CDC
RECOMMENDS CONTINUED LIMITATION
OF ACTIVITIES OUTSIDE THE HOME,
AND A REASSESSMENT IN ANOTHER 72
HOURS. IF AT THAT TIME THE PATIENT HAS
NOT PROGRESSED TO MEET THE CASE
DEFINITION, DISCONTINUATION OF
PRECAUTIONS
CAN BE CONSIDERED AFTER
CONSULTATION WITH THE EVALUATING
CLINICIAN AND LOCAL PUBLIC
HEALTH AUTHORITIES.
FACTORS THAT SHOULD BE
CONSIDERED INCLUDE THE NATURE OF
THE POTENTIAL EXPOSURE TO SARS,
THE NATURE OF CONTACT WITH
OTHERS IN THE RESIDENTIAL OR
WORK SETTING, AND EVIDENCE FOR
AN ALTERNATIVE DIAGNOSIS.
THE
FOLLOWING ARE RECOMMENDED
INFECTION CONTROL MEASURES FOR
PERSONS WITH SARS WHO DO NOT
REQUIRE HOSPITALIZATION, AND FOR
THOSE WHO MAY HAVE SYMPTOMS OF
SARS BUT ARE NOT YET DIAGNOSED.
THESE INDIVIDUALS SHOULD LIMIT
INTERACTIONS OUTSIDE THE HOME TO
THE EXTENT POSSIBLE.
IF TRAVEL OUTSIDE IS NECESSARY,
SUCH AS FOR MEDICAL CARE, A
SURGICAL MASK SHOULD BE WORN and
USE OF PUBLIC TRANSPORTATION
SHOULD BE AVOIDED.
ALSO BY LIMITING PERSONS COMING
INTO THE HOME, OTHER EXPOSURES
WILL BE AVOIDED.
THERE
ARE SEVERAL COMMON-SENSE
MEASURES THAT CAN BE FOLLOWED TO
LIMIT SPREAD OF SARS IN THE
HOME. WITH THE EXCEPTION OF USING A
SURGICAL MASK, THESE APPLY TO
OTHER COMMON RESPIRATORY
INFECTIONS. FOR SARS, USE OF A SURGICAL
MASK
WITHIN THE PRESENCE OF OTHERS IN
THE HOUSEHOLD IS RECOMMENDED.
IN ADDITION, RESPIRATORY
SECRETIONS MAY BE CONTROLLED BY
COUGHING INTO FACIAL TISSUES
THAT ARE THEN PLACED IN LINED
CONTAINERS FOR DISPOSAL WITH
HOUSEHOLD WASTE. HAND HYGIENE FOR ALL
PERSONS IN
THE HOME IS ESSENTIAL.
AND PATIENTS WITH SARS SHOULD
PAY SPECIAL ATTENTION TO HAND
WASHING OR USING AN
ALCOHOL-BASED HAND GEL AFTER
TOUCHING RESPIRATORY SECRETIONS,
AND OTHER BODY FLUIDS, SUCH AS
URINE AND STOOLS.
HOUSEHOLD MEMBERS ALSO SHOULD
PROTECT THEMSELVES FROM
EXPOSURES.
IF THE PATIENT CANNOT WEAR A
MASK, THEN THE SURGICAL MASK
SHOULD BE WORN BY FAMILY MEMBERS
WHEN IN THE SAME ROOM AS THE
PATIENT WITH SARS.
HAND HYGIENE SHOULD BE PERFORMED
FREQUENTLY, PARTICULARLY AFTER
TOUCHING SURFACES THAT MAY BE
CONTAMINATED.
AND FAMILY MEMBERS MAY CONSIDER
WEARING DISPOSABLE GLOVES FOR
CONTACT WITH BODY FLUIDS OF SARS
PATIENTS.
OTHER INFECTION CONTROL MEASURES
ARE ALSO IMPORTANT, SUCH AS NOT
SHARING PERSONAL ITEMS, AND
CLEANING SURFACES THAT ARE
TOUCHED FREQUENTLY, SUCH AS FOOD
PREPARATION AREAS, PHONES AND
LAVATORIES.
CLEANING AGENTS NORMALLY USED IN
THE HOME ARE APPROPRIATE FOR
SARS.
MANUFACTURER RECOMMENDATIONS FOR
USE OF EACH PRODUCT SHOULD BE
FOLLOWED.
SOLUTIONS OF BLEACH CAN ALSO BE
USED FOR CLEANING AND
DISINFECTION.
A 1- TO -100 DILUTION OF BLEACH IN
WATER WHICH TRANSLATES INTO
ABOUT A QUARTER OF A CUP OF
BLEACH PER GALLON OF WATER CAN
BE USED FOR THIS PURPOSE.
CLINICIANS
WILL PLAY AN
IMPORTANT ROLE IN ADDRESSING THE
FEARS AND OTHER CONCERNS OF
FAMILY MEMBERS.
ONE WAY THEY CAN HELP IS BY
ANTICIPATING AND DISCUSSING THE
NEEDS THAT ARE NOT IMMEDIATELY
OBVIOUS, FOR EXAMPLE, HOW A PATIENT WILL
OBTAIN FOOD, MEDICINE, AND OTHER
SUPPLIES, INCLUDING SURGICAL
MASKS, DURING THEIR PERIOD OF
CONFINEMENT; HOW WILL TRAVEL FOR
NECESSARY
APPOINTMENTS BE ARRANGED; HOW SHOULD THEY
DEAL WITH FAMILY
MEMBERS AND NEIGHBORS WHO MAY BE
AFRAID AND DON'T WANT THEM IN
THE HOME OR EVEN IN THE
NEIGHBORHOOD.
ALTHOUGH
THESE MAY SEEM LIKE
MINOR DETAILS, THEY MAY BE
DETERMINANTS IN WHETHER A
PERSON OR OTHER PERSONS BECOME
EXPOSED TO SARS.
THANK
YOU FOR YOUR ATTENTION.
AND I ENCOURAGE YOU TO VISIT THE
CDC WEB SITE FOR ADDITIONAL
INTERIM INFECTION CONTROL
GUIDANCE ON SARS.
>> THANK YOU, LINDA CHIARELLO.
BUT WE HAVE NOW COME TO THE
Q & A PORTION OF THE PROGRAM.
THE NUMBERS TO CALL ARE BY PHONE
800-793-8598.
TTY, 800-815-8152.
AND BY FAX, 800-553-6323.
DR. JAMES LE DUC is DIRECTOR
OF THE DIVISION OF VIRAL
AND RICKETTSIAL DISEASES
AT THE
FOR INFECTIOUS DISEASES
AT THE CENTERS FOR DISEASE
CONTROL. He WILL BE ANSWERING
YOUR QUESTIONS ALONG
WITH THE REST OF OUR PANEL,
THE ONES THAT YOU'VE ALREADY
BEEN INTRODUCED TO.
WELCOME
TO DR. LE DUC.
AND WE'LL GET STARTED WITH A
QUESTION RIGHT OFF THE TOP out
OF
LONG DOES THE CORONAVIRUS LIVE
OUTSIDE OF THE BODY.
>> THAT'S A VERY GOOD QUESTION.
UNFORTUNATELY, WE DON'T HAVE A
WHOLE
BUT AS WE CONTINUE TO LEARN MORE
ABOUT THIS VIRUS, IT'S CLEAR
THAT THIS VIRUS SURVIVES QUITE
WELL IN THE ENVIRONMENT AS
COMPARED TO SIMILAR RNA VIRUSES.
IT LOOKS LIKE AT LEAST OVERNIGHT
ON SOME SURFACES, PERHAPS MUCH
LONGER IN SOME BODILY FLUIDS.
SO CLEARLY THE RECOMMENDATIONS
THAT LINDA HAS SHARED WITH US
ABOUT CLEANLINESS AND WASHING UP
ARE GOING TO BE CRITICALLY
IMPORTANT.
>> Kysa: WE'RE TALKING ABOUT,
LIKE YOU SAID, PRETTY BASIC
THINGS.
BUT HERE'S A QUESTION OUT OF
BESIDES HAND HYGIENE, ARE THERE
OTHER RECOMMENDATIONS FOR PEOPLE
WHO HANDLE PACKAGES FROM SARS
INFECTED AREAS?
>> KYSA, WE HAVE NO INFORMATION
THAT PACKAGES OR OTHER MATERIALS
THAT ARE SENT THROUGH THE MAIL
WOULD POSE A RISK FOR SARS
TRANSMISSION.
IF WE THINK BACK TO WHAT
DR. JERNIGAN SAID ABOUT
TRANSMISSION, IT REALLY DOES
REQUIRE very CLOSE CONTACT WITH AN
INFECTED INDIVIDUAL.
SO WE DO NOT HAVE
RECOMMENDATIONS FOR SPECIAL
HANDLING OF ANY PACKAGES, AND
OTHER THAN GOOD HYGIENE, HAND
HYGIENE THAT WOULD APPLY TO
ANYTHING THAT MAY BE SOILED,
THAT'S WHAT WE WOULD RECOMMEND.
>> Kysa: OKAY.
ANOTHER QUESTION OUT OF
IS IT TRUE THAT THERE ARE OR
HAVE BEEN PROBABLE CASES OF SARS
IN WHICH THERE WAS NO EVIDENCE
OF CORONAVIRUS INFECTION?
IS THIS TRUE?
DR. LE DUC?
>> AS DR. JERNIGAN INDICATED,
AND DEAN ERDMAN CONFIRMED, THIS
IS PRIMARILY A CLINICAL
DIAGNOSIS.
HOWEVER, CONSEQUENTLY, THERE CAN
BE A
DISEASES THAT MIGHT BE CAUSED BY
OTHER AGENTS.
I DON'T KNOW, JOHN, IF YOU WANT
TO FOLLOW UP ON THAT.
>> UNFORTUNATELY, EARLY IN THIS
OUTBREAK WHEN WE DON'T HAVE
WIDESPREAD ACCESS TO DIAGNOSTIC
TESTS, WE'RE STUCK WITH A VERY
NONSPECIFIC CASE DEFINITION.
AND IT'S CLEAR THAT LARGE
PROPORTIONS OF THE PEOPLE WHO
FIT THE CASE DEFINITION FOR SARS
ARE NOT GOING TO BE INFECTED
WITH THE SARS-ASSOCIATED
CORONAVIRUS.
HERE IN THE UNITED STATES, AGAIN
ALTHOUGH WE'RE STILL TESTING
MANY INDIVIDUALS, A VERY SMALL
PROPORTION OF THOSE WHO HAVE MET
THE case DEFINITION ACTUALLY HAVE
EVIDENCE FOR THE INFECTION.
>> Kysa: AND DR. JERNIGAN, THIS
COMES OUT OF
IT SAYS thAT YOUR SLIDE, I BELIEVE
THIS WAS YOUR SLIDE, SAID THAT
SARS TRANSMISSION CAN OCCUR
BEFORE EITHER FEVER OR
RESPIRATORY SYMPTOMS OCCUR.
CAN YOU TELL ME, THE CALLER, IF
TRANSMISSION CAN OCCUR BEFORE
ANY SYMPTOMS ARE APPARENT?
>> I THINK, WHAT I'VE TRIED TO
CONVEY IS THAT THERE IS A PERIOD
OF ILLNESS BEFORE WHICH
RESPIRATORY SYMPTOMS START.
PATIENTS MAY HAVE FEVER,
HEADACHE, MYALGIAS, MALAISE for
THREE to seven DAYS BEFORE
RESPIRATORY SYMPTOMS START.
THERE IS EPIDEMIOLOGIC
EVIDENCE to suggest THAT IN THAT TWO OR
THREE DAYS or more before respiratory symptoms
start, TRANSMISSION CAN
OCCUR.
THERE'S NO epidemiologic EVIDENCE THAT
ASYMPTOMATIC PATIENTS ACTUALLY
TRANSMIT THIS DISEASE.
>> Kysa: OKAY.
IS THERE AN ICD-9 CODE FOR SARS?
DR. LE DUC?
>> I DON'T BELIEVE THERE IS.
>> Kysa: MOVING RIGHT ON.
OUT OF
CAN YOU PROVIDE ANY ADDITIONAL
INFORMATION ON WHY CERTAIN
PEOPLE APPEAR TO BE SUPER
SHEDDERS OR SUPER INFECTORS?
>> AGAIN, THE concept OF THE
SUPER SPREADER OR SUPER SHEDDER
IS AN INTERESTING ONE.
I THINK WE HAVE A LOT MORE epidemiologic WORK
TO DO TO EXPLAIN THAT
PHENOMENON.
AS I SAID, THERE ARE POTENTIAL
FACTORS THAT COULD BE INVOLVED
THAT MIGHT INCLUDE THE HOST,
WHETHER there are HOST FACTORS
THAT ALLOW FOR VERY HIGH VIRAL
REPLICATIONS.
IT'S POSSIBLE THAT THERE ARE
CHANGES IN THE PATHOGEN, FROM
TRANSMISSION TO TRANSMISSION.
ARE THERE GENETIC VARIABLES THAT
IN THE VIRUS ITSELF THAT CHANGE
ITS PATHOGENICITY or its communicability.
Its also possible that THERE MAY BE
ENVIRONMENTAL
FACTORS THAT PLAY A ROLE.
AS WE’ve SAID ALREADY, IN a
HOSPITAL THERE ARE PLENTY OF
OPPORTUNITIES FOR TRANSMISSION, and
THERE MAY BE FACTORS ASSOCIATED
WITH AEROSOL GENERATING EVENTS
THAT CAN LEAD TO A HIGHER communicability
or
ABILITY TO TRANSMIT THE VIRUS.
IT MAY BE A COMBINATION OF
THESE.
I THINK WE NEED A
INFORMATION AND STUDIES BEFORE
WE CAN FULLY UNDERSTAND THIS.
THERE IS SOME EVIDENCE OUT OF
SPREADERS TEND TO HAVE very HIGH
COPIES OF THE VIRUS IN THEIR
RESPIRATORY SECRETIONS.
WHETHER THIS TURNS OUT TO BE
TRUE, WE'LL HAVE TO WAIT AND
SEE.
>> Kysa: CERTAINLY A
LEARN, AS YOU SAID.
THIS QUESTION IS OUT OF
AND DR. ERDMAN, I THINK IT'S ONE
THAT YOU CAN ANSWER.
HOW WILL THE SEQUENCING OF THE
CORONAVIRUS GENOME HELP WITH
TREATMENT.
>> I THINK IN THE FUTURE, THIS
COULD HAVE SOME UTILITY.
CERTAIN DRUGS, OF COURSE, target the
nucleic acid in
THE VIRUS. IN UNDERSTANDING THAT
SEQUENCE AND HOW THOSE TARGETS
ARE IMPORTANT,
WILL BE OF CONSEQUENCE.
ALSO, AS TREATMENTS ARE APPLIED,
WE CAN SEE IF CHANGES OCCUR IN
THAT GENOME THAT MAY REFLECT THE
VIRUS ADAPTING TO, OR BECOMING
RESISTANT TO, THAT PARTICULAR
DRUG.
>> Kysa: OKAY.
OUT OF
DR. LE DUC, CAN YOU please COMMENT ON
THE EPIDEMIOLOGICAL AND
CLINICAL ASPECT OF PEDIATRIC
SARS?
>> THAT'S AN EXCELLENT QUESTION.
IT APPEARS WHEN WE LOOK AT THE
CASES THAT OCCURRED -- HAVE
OCCURRED AROUND THE WORLD, THAT
CHILDREN ARE LESS FREQUENTLY
INFECTED, AT LEAST LESS
FREQUENTLY HOSPITALIZED WITH
SARS AS COMPARED TO ADULTS.
SO IT APPEARS THAT THEY HAVE A
MILDER ILLNESS, ALTHOUGH THERE'S
REALLY VERY LITTLE DATA TO GO
ON.
>> Kysa:
THIS IS OUT OF
AND WE WERE JUST LOOKING AT
THIS.
SHOULD RESPIRATORS BE FIT
TESTED.
AND IF SO, WHERE DO I FIND
INFORMATION ABOUT FIT TESTING?
>> WELL, INFORMATION ON FIT
TESTING IS AVAILABLE ON THE CDC
WEB SITE.
AND NIOSH HAS PROVIDED A very
COMPREHENSIVE RESOURCE OF
INFORMATION ABOUT THAT FIT
TESTING PROCESS.
SO THAT ANSWERED THE SECOND
PART OF THE QUESTION.
IS FIT TESTING IMPORTANT?
YES, IT IS.
A RESPIRATOR IS PART OF A TOTAL,
COMPREHENSIVE RESPIRATORY
PROTECTION PROGRAM.
IT'S VERY IMPORTANT THAT the respirator
PROVIDE A SEAL AROUND THE FACE
SO AIR IS NOT BEING INTRODUCED
INAPPROPRIATELY DURING WEARING
OF THAT DEVICE.
OTHERWISE IT IS NOT A
RESPIRATORY
PROTECTIVE DEVICE.
>> Kysa: I'M NOT QUITE SURE WHO
TO DIRECT THIS QUESTION TO.
IS THERE ANYTHING SPECIFIC TO
LOOK FOR IN AN AUTOPSY?
>> MOST OF THE DATA WE HAVE FROM
PATIENTS WHO HAD
POST-MORTEM EXAMINATIONS, THE
SPECIFIC FINDINGS HAVE BEEN
PRIMARILY DIFFUSE ALVEOLAR
DAMAGE CONSISTENT WITH ARDS,
A VERY NONSPECIFIC FINDING.
THERE DOESN'T APPEAR TO BE, AT
LEAST ON GROSS HISTOPATHOLOGY,
OR ROUTINE histopathologic EXAMINATION,
MUCH
INVOLVEMENT OF TISSUES OUTSIDE
THE RESPIRATORY TRACT.
SO THE MAJOR HISTOPATHOLOGIC
FINDING and finding on autopsy HAS been
DIFFUSE ALVEOLAR
DAMAGE IN THE LUNGS.
>> Kysa: ANOTHER HYGIENIC
QUESTION OUT OF
HOW DO YOU CLEAN GOGGLES, OR
SHOULD THEY, TOO, BE INDIVIDUAL
USE?
I'M NOT QUITE SURE I UNDERSTAND
THAT.
DO YOU UNDERSTAND THAT?
>> CERTAINLY, IF THEY'RE GOING
TO BE USED FROM ONE HEALTH CARE
WORKER TO ANOTHER, THEY NEED TO
BE CLEANED using disinfectant.
AND --
>> Kysa: OKAY.
>> BETWEEN USES.
IN TERMS OF THE CLEANING PROCESS
ONE WOULD HOPE THAT IN ANY
HEALTH CARE FACILITY, THE
PROCEDURES FOR CLEANING REUSABLE
EQUIPMENT AFTER USE IN AN
ISOLATION AREA WOULD BE IN
PLACE.
AND SO THE
REPROCESSING USED GOGGLES AND
OTHER PERSONAL PROTECTIVE
EQUIPMENT SHOULD BE USED.
AND THAT WOULD BE THE CLEANING
AND DISINFECTION OF THAT
EQUIPMENT.
>> Kysa: OKAY.
AND IF WE CAN GET ANOTHER
QUESTION OVER HERE QUICKLY.
MOVE RIGHT ON.
OKAY.
THIS ONE, IT'S MY UNDERSTANDING
VARIOUS CLEANSING AGENT CAN KILL
THE VIRUS.
CAN YOU BE MORE SPECIFIC ON WHAT
TYPES AND HOW TO USE?
>> THERE'S A LOT OF WORK GOING
ON IN THIS AREA.
AND WE DON'T HAVE ALL THE
ANSWERS YEt.
THIS IS A lipid envelope VIRUS, and BASED
ON
EXPERIENCE WE HAVE WITH OTHER
lipid envelope VIRUSES, WE THINK THAT
MOST DETERGENTS SHOULD BE ABLE
TO TAKE CARE OF THIS VIRUS.
AND CERTAINLY, WE HAVE NO REASON
TO BELIEVE THAT EPA REGISTERED
DISINFECTANTS THAT ARE USED
COMMONLY IN THE HOME OR IN THE
HEALTH CARE SETTING WOULD NOT BE
ADEQUATE FOR THIS VIRUS.
Again, THERE ARE A NUMBER OF
ENVIRONMENTAL STUDIES GOING ON,
AND WE HOPE TO HAVE MORE
INFORMATION ON THIS IN THE
FUTURE.
IN GENERAL, THERE'S NO REASON TO
BELIEVE THIS VIRUS WOULD BE
PARTICULARLY HARD TO ELIMINATE
FROM AN ENVIRONMENTAL SURFACE
WITH PRETTY ROUTINE CLEANING
MEASURES.
>> Kysa: WITH SUMMER APPROACHING
HERE'S A TIMELY QUESTION.
IS THERE ANY EVIDENCE OF HOW --
OR IF THE SARS VIRUS CAN LIVE IN
WATERWAYS?
>> I THINK THIS IS AN EXCELLENT
QUESTION.
AND ONE THAT WE'LL BE TRYING TO
SYSTEMATICALLY ANSWER IN
THE FUTURE.
GIVEN THAT AS KYSA SAID, THE
WARMER MONTHS ARE AHEAD OF US.
WE DON'T REALLY KNOW THE ANSWER
TO THAT QUESTION YET, BUT WE'LL
CERTAINLY BE LOOKING INTO IT.
>> Kysa: THIS IS OUT OF
THIS QUESTION.
IT WAS MENTIONED THAT INITIAL
CHEST X-RAYS IN SARS MAY BE
IS IT, THEREFORE, NECESSARY TO
OBTAIN FOLLOW-UP CHEST X-RAYS?
>> YEAH, I THINK SO.
IF YOU HAVE A PATIENT WHO HAS
THE RIGHT EPIDEMIOLOGIC
EXPOSURE AND HAS AN ILLNESS
THAT'S CONSISTENT yet HAS A
NORMAL CHEST X-RAY ON ADMISSION,
IF YOU'RE STILL HIGHLY
SUSPICIOUS THAT THIS PATIENT MAY
HAVE SARS, I THINK AN
APPROPRIATE MEASURE WOULD BE TO
FOLLOW UP WITH SERIAL CHEST
X-RAYS.
>> Kysa: THE QUESTIONS CONTINUE
TO COME IN.
IS THERE EVIDENCE OF REINFECTION
WITH SARS?
>> IT'S EARLY IN THE OUTBREAK.
AND WE DON'T HAVE A
INFORMATION there.
THERE IS EVIDENCE FROM OTHER
HUMAN CORONAVIRUSES THAT
REINFECTION CAN OCCUR.
AND IT'S QUITE POSSIBLE THAT
THAT MIGHT BE THE SAME WITH THIS
CORONAVIRUS.
BUT I THINK IT'S JUST TOO EARLY
TO TELL YET.
>> Kysa: CERTAINLY A
PEOPLE, AND WE'VE TOUCHED ON
THIS, ARE A LITTLE LEERY, in particular
you did.
THIS CALLER WANTS TO KNOW, IF
SOMEONE IS DIAGNOSED WITH SARS,
AND THEY WERE SITTING, SAY, IN A
CROWDED OR A WAITING ROOM,
SHOULD THE PATIENTS THAT WERE IN
THE WAITING ROOM WITH THEM BE
NOTIFIED THAT THEY WERE EXPOSED
TO SARS?
AND THEREFORE, BE QUARANTINED? Dr.
Jernigan, Ms. Chiarello?
>> PERHAPS WE CAN BOTH ADDRESS
THIS.
>> SURE.
I THINK THE QUESTION BASICALLY
IS WHAT IS CLOSE CONTACT.
IF YOU LOOK AT OUR -- THE MOST
RECENTLY released CASE DEFINITION, I
THINK WE ADDRESSED THIS.
AND CLOSE CONTACT IS DEFINED BY
REALLY PRETTY INTIMATE CONTACT,
THAT YOU MIGHT EXPECT IN THE
HOME, OR IF YOU'RE HAVING CARED
FOR SOMEBODY, EITHER IN THE HOME
OR IN THE HEALTH CARE SETTING.
WE ALSO THINK THAT HAVING A
CLOSE FACIAL CONTACT DURING
CONVERSATION COULD BE INCLUDED
IN THAT LIST, OR SHARING EATING
UTENSILS, OR OTHER UTENSILS IN
THE HOME THAT MIGHT TOUCH THE
MUCOSAL SURFACES.
WE DON'T THINK SITTING ACROSS
THE WAITING ROOM FOR A SHORT
PERIOD OF TIME PROBABLY
REPRESENTS AN EXPOSURE TO SARS.
I DON'T KNOW IF YOU HAVE
ANYTHING TO ADD TO THAT, LINDA.
>> I think that’s correct, and I
THINK THE MESSAGE, TOO, IS
WE REALLY WANT TO ENCOURAGE
HEALTH CARE FACILITIES,
ESPECIALLY OUTPATIENT AREAS AND
EMERGENCY ROOMS, TO PUT IN THE
MEASURES IN PLACE FOR THE EARLY
detection OF SARS PATIENTS WHO MAY
BE COMING THROUGH.
THAT EARLY TRIAGE PROCEDURE, TO
IDENTIFY PERSONS WHO MAY HAVE
SYMPTOMS OF SARS, OR HAVE
TRAVELED OR HAD THE SARS
EXPOSURE.
AND THEN IF THERE ARE SYMPTOMS,
HAVING THAT INDIVIDUAL PUT ON A
SURGICAL MASK.
THAT'S COMMON SOURCE CONTROL TO
PREVENT THE -- HAVING THEM
COUGHING INTO THE ENVIRONMENT
AND EXPOSING OTHER INDIVIDUALS.
I THINK THAT'S IMPORTANT.
>> Kysa: THE NEXT QUESTION, I'M
NOT SURE THE DISEASE HAS BEEN
AROUND LONG ENOUGH FOR YOU TO
PROPERLY ANSWER THIS, BUT THE
PERSON WANTS TO KNOW, IS THERE
ANY EVIDENCE OR INFORMATION THAT
SARS AFFECTS PEOPLE SEASONALLY?
>> THAT'S ANOTHER GOOD QUESTION
THAT WE REALLY DON'T HAVE THE
ANSWER FOR YET.
CLEARLY THIS -- THE EXPERIENCES
WE'RE SEEING NOW ARE PRIMARILY
RESPIRATORY TRANSMISSION.
HOWEVER, AS WE ENTER WARMER
MONTHS IN THE NORTHERN
HEMISPHERE, THE POSSIBILITY OF
FECAL/ORAL TRANSMISSION IS VERY
REAL AND WE MAY IN FACT SEE A
SUMMERTIME PEAK AS WELL.
SO AT THIS POINT WE REALLY DON'T
KNOW.
>> Kysa: AND DR. LE DUC, WHAT IS
THE DURATION OF THE ILLNESS THAT
WHY YOU'RE SEEING FOR THOSE considered to
have RECOVERED FROM SARS?
>> I THINK PROBABLY DR. JERNIGAN
IS A BETTER ANSWERERER OF THIS.
>> Kysa: SURE.
>> Again, WE'RE LEARNING MORE ABOUT
THIS.
BUT IT DOES APPEAR THAT PATIENTS
CAN HAVE A MILD ILLNESS FOR A
PERIOD OF TIME BEFORE THEY
DEVELOP A SEVERE ILLNESS.
IT'S POSSIBLE THAT PEOPLE MAY BE
BEFORE THEY -- IF THEY ARE -- IF
THEY PROGRESS, BEFORE THEY
PROGRESS TO THE SEVERE STAGES.
I THINK, YOU KNOW, INTO THE
SECOND AND THIRD WEEK OF ILLNESS
PEOPLE ARE BEGINNING TO RECOVER
BY THAT TIME.
>> LET ME JUST ADD THAT IT
APPEARS THAT SOME PATIENTS ALSO
HAVE A PROLONGED CONVALESCENCE.
THEY DON'T REALLY FEEL AS
THEMSELVES FOR QUITE SOME TIME.
>> Kysa: OKAY.
AND THIS QUESTION OUT OF
IS THERE ANY GROUP OF
INDIVIDUALS -- ANY GROUP THAT IS
AT HIGHER RISK WHEN THEY TRAVEL
TO REGIONS WITH SARS?
ANY GROUP OF PEOPLE?
>>
WELL, IT'S HARD TO SAY,
BEFORE WE
HAVE MORE EPIDEMIOLOGY what the actual risk factors are
OTHER THAN
HAVING HAD DIRECT
CONTACT
WITH A PATIENT WHO'S
KNOWN OR
SUSPECTED TO HAVE SARS.
>>
Kysa: AND LET ME TRY TO WADE
THROUGH
THIS ONE.
SHOULD
INDUSTRIAL LAUNDRY REFUSE
SARS-SOILED
LINEN, OR WHAT TPE
IS
REQUIRED IF THE LINEN IS
ACCEPTED
ON SITE.
>> I
THINK, FIRST OF ALL, IT
WOULD BE
DIFFICULT TO DETERMINE
WHAT LINEN
MAY OR MAY NOT BE
SOILED
FROM PATIENTS WITH SARS.
BECAUSE
INFECTIOUS LINEN COMES
FROM MANY
PATIENTS, AND IT JUST
DOESN'T
CONTAIN THE SARS VIRUS.
CDC
RECOMMENDS THAT PROCEDURES
TO
ROUTINELY HANDLE ALL LINEN AS
IF IT'S
POTENTIALLY CONTAMINATED
BEING
PLACED IN HOSPITAL AND
INDUSTRIAL
LAUNDRY CENTERS.
SO WE
WOULD NOT RECOMMEND ANY
DIFFERENT
-- ANYTHING DIFFERENT
FOR THE
HANDLING OF THE LINEN.
IT SHOULD
BE PROPERLY BAGGED,
AND
PERSONNEL IN THE COURSE OF
HANDLING
ANY SOILED LINEN SHOULD
AVOID
DIRECT CONTACT WITH THAT
MATERIAL,
SHOULD AVOID ANYTHING
THAT WOULD
AEROSOLIZE LINEN IN
GENERAL IN
the course of HANDLING IT. So the
LIMITED
HANDLING WITH ALL SOILED
LINEN IS
WHAT WE WOULD NORMALLY
RECOMMEND.
>>
Kysa: LET'S SEE IF I'M UP
WITH MY MEDICAL
JARgON.
IT SAYS
ADDRESS pre-HOSPITAL USE,
AND IN
PARENTHESES, AMBOS, AND I’m thinking this is ambulances,
of
nebulizer TREATMENT and OF INTUBATION.
DO
AMBULANCE DRIVERS NEED TO
TAKE
SPECIAL PRECAUTIONS.
>>
THERE IS GUIDANCE ON OUR WEB
SITE
SPECIFICALLY FOR
PRECAUTIONS
DURING AMBULANCE
TRANSPORT
OF PATIENTS.
AND THOSE
PRECAUTIONS ARE VERY
SIMILAR TO
THE ONES THAT HAVE
BEEN
OUTLINED HERE.
AND I
ENCOURAGE YOU TO CHECK THE
WEB SITE
FOR A VERY DETAILED
LISTED OF
THOSE.
THEY'RE
PRETTY BASIC USE OF
PERSONAL
PROTECTIVE EQUIPMENT.
IF A
PATIENT DID REQUIRE
INTUBATION,
OR VENTILATION, IN
THAT
SETTING, THOSE are AEROSOL
GENERATING
EVENTS, AND IF
UNPROTECTED,
THAT WOULD BE
CONSIDERED
A HIGH-RISK EXPOSURE.
THE PROPER
PERSONAL PROTECTIVE
EQUIPMENT
IS RECOMMENDED.
AND HOW TO
HANDLE THAT SITUATION
AFTER ONE
MIGHT OCCUR WOULD HAVE
TO BE
HANDLED ON A CASE-BY-CASE
BASIS.
BUT I
WOULD ENCOURAGE YOU TO
VISIT OUR
WEB SITE AND LOOK AT
THE
GUIDANCE FOR PROTECTION AND
PRECAUTION
TO TAKE DURING
AMBULANCE
TRANSPORT.
>>
Kysa: AND WHAT ARE SOME OF
THE
HYPOTHESeS REGARDING THE
ORIGINATION
OF THE VIRUS?
>>
WELL, AS DR. ERDMAN SHARED
WITH US,
THIS GROUP OF VIRUSES
IS VERY
COMMON IN A NUMBER OF
DIFFERENT
ANIMAL SPECIES.
SO
CERTAINLY ONE HYPOTHESIS IS
THAT THIS
VIRUS HAS SOME ORIGIN
IN
ANIMALS, PERHAPS WILD ANIMALS,
AND IT'S
SOMEHOW BECOME
INTRODUCED
INTO THE HUMAN
POPULATION
PERHAPS AS A FOOD
SOURCE, OR
WHO KNOWS HOW.
WE HAVE
REALLY NO IDEA.
BUT IT'S
CERTAINLY AN INTRIGUING
AREA FOR
FUTURE INVESTIGATIONS.
>>
Kysa: AND NOW, SOMEONE FROM
YOU GIVE
MORE DETAILS ON
INFORMATION
REPORTs ABOUT
RELAPSES
OF PATIENTS?
>>
WE, OF COURSE, IN THE PRESS,
IT WAS
REPORTED A COUPLE OF
WEEKS AGO
THAT THERE MAY HAVE
BEEN SOME
RELAPSES IN
I THINK
THERE'S SOME INFORMATION
SINCE THAT
TIME THAT SUGGESTS
THAT THAT MAY NOT BE QUITE THE
CASE.
I CAN SAY
THAT WE'VE LOOKED AT
THE SMALL
NUMBER OF PATIENTS
WE'VE HAD
HERE, AND HAVE NOT
SEEN ANY
REAL RELAPSES
DESCRIBED.
I'VE BEEN
IN TOUCH WITH OUR
COLLEAGUES
IN
HAVE NOT
BEEN any RELAPSES
DESCRIBED
IN THAT SETTING
EITHER.
SO I THINK
WE NEED A LITTLE MORE
TIME TO
SORT THAT OUT AND SEE
EXACTLY
WHAT THE STORY ON THAT
IS.
RIGHT NOW,
I DON'T THINK THERE'S
REAL SOLID
EVIDENCE THAT THERE
ACTUALLY
IS RELAPSE.
IT COULD
BE THAT THIS IS A
MANIFESTATION
OF WITHDRAWING
SOME OF
THE IMMUNOSUPPRESSIVE
TREATMENTS and the CORTICOSTEROIDS
and withdrawing other therapy,
BUT I THINK WE JUST
NEED MORE TIME TO SORT THAT OUT.
>> Kysa:
THIS QUESTION DEALS
WITH SARS IN THE HOME.
HOW DO YOU DISPOSE OF MASKS AND
OTHER CONTAMINATED MATERIALS IN
THE HOME?
MS. CHIARELLO.
>> AT THE PRESENT TIME, WE
ONLY
RECOMMEND THAT SOILED MATERIALS,
CONTAMINATED MATERIALS, BE BAGGED
AND DISPOSED WITH THE REGULAR
HOUSEHOLD WASTE, WHICH IS THE
SAME THING WE WOULD RECOMMEND
FOR ANY OTHER INFECTIOUS
MATERIAL THAT WAS IN THE HOME.
SO THERE'S NOTHING SPECIAL OR
DIFFERENT.
BUT IT IS IMPORTANT TO CONTAIN
THAT MATERIAL IN SOME KIND OF
PLASTIC BAG FOR DISPOSAL.
AND THEN PUT IT WITH THE REGULAR
TRASH.
>> Kysa:
GETTING A
QUESTIONS OUT OF
HOW LONG ARE SURGICAL MASKS
PROTECTIVE?
>> I THINK THE QUESTION IS
REALLY, HOW LONG CAN ONE WEAR A
SURGICAL MASK, OR A RESPIRATOR
IF THAT'S WHAT THEY'RE USING.
AND WE GENERALLY RECOMMEND THAT
MASKS, SURGICAL MASKS AND
RESPIRATORS BE DISPOSED AFTER A
SINGLE USE.
NOW, IN THE HOME SETTING, THIS
MAY NOT BE PRACTICAL.
AND SO WITHIN THE HOME, IT
SHOULD BE SINGLE-PERSON USE,
FIRST OF ALL.
AND THEN WHEN THEY BECOME SOILED
OR MOIST, THAT'S THE APPROPRIATE
TIME.
WE DON'T HAVE A SPECIFIC
HOUR TIME, OR HOURLY TIME
INTERVAL AFTER WHICH THEY'RE NO
LONGER EFFECTIVE.
BUT THEY DO BECOME SOILED AND WE
WOULD RECOMMEND AT LEAST
DISPOSING OF THEM ON A DAILY
BASIS.
AND THE SAME THING WOULD APPLY
IN A HEALTH CARE SETTING,
DISPOSING OF THEM AFTER SINGLE
USE IS PREFERRED.
IF THEY ARE REUSED, DISPOSING OF
THEM IDEALLY AT THE END OF THE
DAY WOULD BE THE PREFERRED
OPTION.
>> Kysa:
OKAY.
AND A PERSON OUT OF
WRITES, EMERGENCY ROOMS DON'T
HAVE ANY NEGATIVE AIR PRESSURE.
THE QUESTION IS, WHAT MEASURES
SHOULD BE TAKEN?
>> THIS REALLY GOES BACK TO
WHAT
I MENTIONED EARLIER, IN TERMS OF
THE SOURCE CONTROL CONCEPT AND
HAVING PATIENTS WHO ARE
SYMPTOMATIC WITH SARS, AND EVEN
ANY RESPIRATORY DISEASE, REALLY,
COULD BE PUTTING ON A SURGICAL
MASK TO PROTECT THEMSELVES, SO that
THERE IS THAT SOURCE CONTROL.
WITHIN THE EMERGENCY ROOMS, MANY
DON'T HAVE THE NEGATIVE PRESSURE
ENVIRONMENT AS MIGHT BE USED IN
AN INPATIENT SETTING.
AND IT'S POSSIBLE THROUGH THE
SOURCE CONTROL, AND THROUGH
OTHER -- TRYING TO ALTER THE
VENTILATION IN THAT ROOM SO THAT
BY PUTTING THE PATIENT PERHAPS
IN AN AREA WHERE THEY'RE MORE
REMOVED FROM OTHER PATIENTS, A
DISTANCE AWAY, HAVING THE HEALTH
CARE PERSONNEL WEAR THE
RECOMMENDED PROTECTIVE ATTIRE,
AND JUST TRYING TO PROVIDE A
SPACE FOR THOSE INDIVIDUALS.
WE HAVE SAID THAT IF IT'S
POSSIBLE, TO EXHAUST THE AIR TO
THE OUTSIDE.
BUT I REALIZE THAT THAT'S NOT A
VERY PRACTICAL SOLUTION.
AT LEAST FOR EMERGENCY ROOMS.
>> Kysa:
DR. JERNIGAN?
>> If I could add to that, I
JUST WANT TO EMPHASIZE THAT
ALTHOUGH WE'RE still LEARNING ABOUT
THE EPIDEMIOLOGY AND
TRANSMISSION OF THIS ILLNESS,
MOST OF THE TRANSMISSION AND
MOST OF THE EPIDEMIOLOGY
SUGGESTS THAT TRANSMISSION
OCCURS IN THE VAST MAJORITY OF
CASES BY EITHER CLOSE CONTACT
WITH LARGE DROPLET AEROSOLS, OR
direct contact or perhaps
INDIRECT CONTACT.
AIRborne TRANSMISSION DOESN'T
SEEM TO BE THE MAJOR MODE OF
TRANSMISSION.
THERE ARE certain SETTINGS THAT WE
TALKED ABOUT some TODAY,
SPECIFICALLY
THESE AEROSOL GENERATING
PROCEDURES, WHERE THAT MAY BE A
PARTICULAR CONCERN.
EVEN IF YOU DIDN'T HAVE A
NEGATIVE PRESSURE ROOM,
IDENTIFYING THE PATIENT QUICKLY,
PUTTING THEM IN A ROOM BY
THEMSELVES even if it’s not
negative pressure IS PROBABLY GOING TO
GO MOST OF THE WAY TOWARDS
PREVENTING OTHER TRANSMISSIONS.
IF THERE IS A NEED FOR AN
AEROSOL GENERATING PROCEDURE,
THEN IN THAT PARTICULAR CASE, I
MIGHT DEFER UNTIL YOU WERE IN A
NEGATIVE PRESSURE SETTING.
>> Kysa:
AND WE HAVE A QUESTION
FROM
WHAT IS THE OPINION OF THE PANEL
ON WHY WE HAVEN'T SEEN ANY
DEATHS IN THE UNITED STATES?
THAT'S AN EXCELLENT QUESTION.
>> WELL, IT'S A GOOD
QUESTION.
I'LL TAKE A FIRST CRACK, AND
I'LL SEE WHAT THE OTHERS SAY.
ONE POSSIBLE EXPLANATION is THAT WE
JUST HAVEN'T SEEN THAT MANY REAL
CASES IN THE UNITED STATES.
WE'VE ONLY HAD SIX LABORATORY
CONFIRMED CASES SO FAR
OF PATIENTS WITH SARS
CORONAVIRUS INFECTION.
AND HAVING NO DEATHS MAY NOT BE
SIGNIFICANTLY DIFFERENT FROM
WHAT'S BEEN REPORTED IN SOME OF
THE OTHER COUNTRIES.
IT'S ALSO POSSIBLE THAT THERE
MAY BE DIFFERENCES IN THE WAY
THAT WE -- THE VIRUS HAS COME
INTO OUR COUNTRY.
IT'S
POSSIBLE THAT THE SO-CALLED
SUPER SHEDDERS MAY BE, FOR
WHATEVER REASON, TRANSMITTING
HIGH NUMBERS OF VIRUS OR MAY BE
DIFFERENCES IN THE virulence of the
STRAIN OF THE
VIRUS THAT THEY'RE SPREADING.
WE DON'T KNOW.
THOSE COULD BE RELATED TO
MORTALITY.
IT MAY JUST BE THAT WE HAVE NOT
HAD ANY OF THOSE PARTICULAR
INDIVIDUALS YET IN THIS COUNTRY.
WE SIMPLY DON'T KNOW.
>> Kysa:
WOULD YOU LIKE TO ADD
TO THAT, DR. LE DUC?
>> WELL, OF THose SIX PATIENTS,
ALL OF THEM HAD PNEUMONIA.
TWO OF THEM WERE IN ICUs, AND I
THINK ONE OF THEM AT LEAST
REQUIRED VENTILATION.
SO CLEARLY, THESE PATIENTS WERE
NOT SUFFERING FROM A MILD
ILLNESS.
I THINK SO FAR THE NUMBERS ARE
JUST SMALL, AND I SUSPECT THAT
OVER TIME WE'RE LIKELY TO SEE A
FATALITY.
>> Kysa:
OKAY.
LISA FROM
TO KNOW, IS CDC CONSIDERING
EXPANDING THE TEN-DAY PERIOD
AFTER EXPOSURE PER CURRENT CASE
DEFINITION?
>>There are NO PLANS THAT I'M
AWARE OF TO
EXPAND THAT NUMBER NOW.
AGAIN, FOR THOSE CASES IN WHICH
WE HAVE THE MOST WELL-DEFINED
EXPOSURES, IT SEEMS that THE
INCUBATION PERIOD DOES FALL IN
THAT THREE TO TEN-DAY PERIOD.
SO WE HAVE NO IMMEDIATE PLANS TO
CHANGE THAT RIGHT NOW.
>> Kysa:
OKAY.
ANOTHER QUESTION FROM
SALLY.
WHAT ARE CONCERNS FOR
CONTAINMENT OF THE VIRUS PER
RECENT INFORMATION THAT THE
VIRUS MAY BE MUTATING?
>> I THINK THE UNMUTATED
VIRUS
HAS -- IS SUFFICIENT FOR
CONCERN.
AND I THINK THE EVIDENCE THAT
THE VIRUS IS MUTATING
SUBSTANTIALLY IS REALLY NOT
THERE YET.
WE'RE WAITING TO SEE IF THIS IS
IN FACT THE CASE.
>> Kysa:
HAVE THEY SEEN OTHER OUTBREAKS
WITH THE CORONAVIRUS IDENTIFIED
IN THE PAST, AND WHAT HAS BEEN
THE CDC'S RESPONSE?
>> WELL, AGAIN, THERE ARE
OTHER
KNOWN HUMAN CORONAVIRUSES.
FORTUNATELY, THOSE CORONAVIRUSES
tend to cause only a very
MILD UPPER
RESPIRATORY ILLNESS, SIMILAR TO
THE COMMON COLD.
THERE MAY HAVE BEEN, MAY BE SOME
ASSOCIATED WITH A FEW CASES OF
PNEUMONIA.
BUT IN GENERAL, IT'S BEEN A MUCH
MORE MILD ILLNESS THAN WHAT
WE'RE SEEING HERE.So
THERE'S been REALLY BEEN NO NEED
FOR
A MAJOR PUBLIC HEALTH RESPONSE
IN THE PAST.
>> Kysa:
OUT OF
THERE ANY EVIDENCE THAT SARS CAN
BE TRANSMITTED BY INSECTS?
I'M NOT AWARE OF ANY.
>> I'M NOT AWARE OF ANY
EVIDENCE.
>> Kysa:
NO EVIDENCE?
>> LET ME JUST ADD, HOWEVER,
THAT THE FACT THAT WE'RE NOW
SEEING EVIDENCE OF THE VIRUS
SURVIVING IN THE ENVIRONMENT,
BEING PRESENT IN FECES AND OTHER
BODILY FLUIDS, ALL OF THIS LENDS
ONE TO BELIEVE THAT GENERAL
HYGIENE ISSUES ARE CERTAINLY
IMPORTANT.
AND WE WANTED TO MAKE SURE THAT
ADEQUATE HYGIENE EFFORTS ARE IN
PLACE, ESPECIALLY AROUND KNOWN
CASES.
SO WE DON'T WANT TO TEST THAT
HYPOTHESIS about insect
transmission UNNECESSARILY.
>> Kysa:
WHAT EVIDENCE EXISTS
THAT SARS INFECTION COULD BE
AIRBORNE?
>> WELL, AGAIN, THERE'S --
THE
EPIDEMIOLOGY THAT WE know OF
SO FAR WOULD SUGGEST THAT IN THE
VAST MAJORITY OF CASES,
TRANSMISSIONs were NOT BY THE
AIRBORNE ROUTE.
AGAIN, THERE ARE WORRISOME
EXAMPLES OF TRANSMISSION THAT
SUGGEST THAT AIRBORNE MAY HAVE
PLAYED A ROLE.
SOMETIMES IT CAN BE VERY
DIFFICULT epidemiologically TO SORT
OUT AIRBORNE
TRANSMISSION from INDIRECT fomite
TRANSMISSION.
WE HAVE MORE EPIDEMIOLOGY TO DO.
AGAIN, IN GENERAL, WE THINK THE
MAJOR MODE OF TRANSMISSION IS
either
LARGE DROPlets
OF AEROSOL, COMING IN
close CONTACT WITH THE PATIENT,
OR DIRECT OR INDIRECT CONTACT.
There are certain settings in which aerosolize or
AIRBORNE TRANSMISSION CAN'T BE
RULED OUT.
>> Kysa:
ANOTHER QUESTION FROM
FOR PATIENTS WITH A POSITIVE
TRAVEL OR EXPOSURE HISTORY
WHO HAVE ONE SYMPTOM, DO THEY
NEED A FACE-TO-FACE EXAM OR
SHOULD THEY STAY HOME SIMPLY FOR
THE 72-HOUR WAIT-AND-SEE PERIOD?
>> I THINK IT'S A GOOD
QUESTION.
AND I THINK IT'S A CLINICAL
JUDGMENT.
IF A PHYSICIAN TALKS TO A
PATIENT WHO HAS PERHAPS A MILD
ILLNESS, DOESN'T SOUND LIKE THEY probably
MEET THE CASE DEFINITION
from talking to THEM OVER THE
PHONE, IT COULD BE APPROPRIATE
TO ADVISE THE PERSON OVER THE
PHONE AND THEN REEVALUATE AND
MAKE A CLINICAL JUDGMENT ON
WHETHER OR NOT ONE SHOULD
PRESENT TO AN OUTPATIENT SETTING
FOR EVALUATION.
I THINK IT IS IMPORTANT TO
COMMUNICATE THAT, IF A PATIENT
DOES FEEL LIKE THEY NEED TO
PRESENT FOR EVALUATION, THEY
SHOULD NOTIFY THEIR HEALTH
CAREGIVER IN ADVANCE SO THAT
PREPARATIONS CAN BE MADE TO MEET
THEM AND MAKE SURE THAT THE
APPROPRIATE INFECTION CONTROL
PRECAUTIONS ARE TAKEN AT THE
MOMENT THEY HIT THE DOOR,
INCLUDING PERHAPS PUTTING A MASK
ON THE PATIENT AND OTHER THINGS
THAT THE FACILITY MAY WANT TO
DO.
>> Kysa: SOMEONE FROM
WANTS TO KNOW, ARE THERE
ANTI-VIRAL DRUGS IN DEVELOPMENT
FOR THE SARS CORONAVIRUS?
>> WE'RE WORKING VERY CLOSELY
WITH THE NATIONAL INSTITUTES OF
HEALTH AND OTHER LABORATORIES IN
EXAMINING ALL OF THE LICENSED
ANTI-VIRAL DRUGS CURRENTLY
MARKETED, AS WELL AS THOSE IN
THE PIPELINE TO SEE WHICH, IF
ANY, WILL BE SHOWN TO BE efficacious
IN TREATING THIS VIRUS.
SO FAR, WE DON'T HAVE ANY HITS,
BUT THERE'S LITERALLY THOUSANDS
OF COMPOUNDS THAT WE'RE PLOWING
THROUGH.
>> Kysa: THIS IS A TRANSMISSION,
A TYPED QUESTION.
DOES TEMPERATURE OR HUMIDITY
HAVE AN EFFECT ON THE SURVIVAL
OF THE SARS VIRUS ON SURFACES?
>> WELL, THERE'S BEEN LIMITED
STUDIES with THE
HUMAN
CORONAVIRUSES, AND SOME OF THE
VARIABLES THEY'VE LOOKED AT HAVE
BEEN TEMPERATURE, HUMIDITY, THE
TYPE OF SURFACE.
AND ALL OF THOSE DO INDEED
AFFECT THE SURVIVABILITY OF THE
VIRUS.
THOSE VARIABLES WILL BE LOOKED
AT IN THIS CASE AS WELL.
>> Kysa: THEN OUT OF
DOES THE PANEL RECOMMEND THAT
E.R.s CLOSE FOR A CERTAIN PERIOD
OF TIME AFTER A SARS PATIENT HAS
BEEN IDENTIFIED?
>> AND I BELIEVE -- ON MY PART, NO,
I WOULD SAY
NO, WE HAVE NO RECOMMENDATION.
THAT THERE'S ANY INDICATION TO
CLOSE AN EMERGENCY ROOM.
AS DR. JERNIGAN ALREADY
MENTIONED, IT REALLY IS A very CLOSE
CONTACT WITH PATIENTS.
AND WE DON'T BELIEVE THAT THERE
IS AN INDICATION TO GO TO THAT
EXTREME AT THIS POINT IN TIME.
>> Kysa: GETTING A
QUESTIONS IN.
THIS ONE IS, WHAT IS THE RISK TO
COMMERCIAL AIRLINES -- WHAT IS
THE RISK ON COMMERCIAL AIRLINES
TO AND FROM afFECTED AREAS?
SAY someone flying FROM
STATES, OR VICE VERSA.
>> THAT'S A VERY IMPORTANT
QUESTION.
THAT'S BEING LOOKED AT BY A
NUMBER OF GROUPS AROUND THE
WORLD.
THERE ARE A NUMBER OF COHORT
STUDIES THAT ARE BEING CONDUCTED
IN AN INTERNATIONALLY
COLLABORATIVE WAY.
FLIGHTS IN WHICH PATIENTS WHO
HAD KNOWN OR SUSPECT SARS,
FLIGHTS ON WHICH THOSE PERSONS
TRAVELED.
THERE HAVE BEEN REALLY A VERY
LIMITED NUMBER OF DOCUMENTED
TRANSMISSIONS IN THAT SETTING.
AND WHEN YOU LOOK AT THE
DENOMINATORS OF THE PASSENGERS
WHO TRAVELED ON THOSE FLIGHTS,
IT WOULD APPEAR THAT THE RISK IS
VERY, VERY, VERY LOW.
HOWEVER, THOSE STUDIES ARE
ONGOING AND WE HOPE TO HAVE A
MORE QUANTITATIVE ASSESSMENT OF
THAT IN THE NEAR FUTURE.
>> Kysa: MARK FROM
TO KNOW WHAT THE PANEL THINKS
ABOUT UNIVERSITIES AND THEIR
POLICIES WITH REGARD TO ASKING
STUDENTS TO WAIT TEN DAYS per
EXPOSURE.
AND HOW MUCH DO THEY TAKE IN
ACCOUNT LOCAL MEDICAL RESOURCES.
AND THEN WE HAVE ADVICE ON THIS
SITUATION, COLLABORATIVE EFFORT,
I GUESS THEY'RE ASKING.
>> YES.
THAT'S A VERY GOOD QUESTION.
AND CLEARLY IN THE NEWS
CURRENTLY.
I THINK THAT OUR GUIDANCE WOULD
BE SIMILAR TO THAT FOR PERSONS
THAT ARE ASYMPTOMATIC AND
POTENTIALLY EXPOSED.
I THINK MONITORING self--TAKING
YOUR TEMPERATURE TWICE A DAY,
BEING COGNIZANT OF YOUR HEALTH,
WOULD BE APPROPRIATE.
I THINK AS STATED, WE WOULD NOT
INTERRUPT YOUR
>> AND JUST TO ADD, I WOULD
AGREE WITH THAT, BUT TO ADD TO
THAT, I THINK WE ARE -- WE DO
NEED TO FORMULATE SOME GUIDANCE
ON WHAT TO DO IF YOU'RE
EXPECTING a LARGE INFLUX OF
PATIENTS WHO MIGHT BE
POTENTIALLY EXPOSED.
AND WE ARE GATHERING TOGETHER
WORKING GROUPS AS WE SPEAK TO
COME UP WITH BETTER DEFINITIVE,
MORE DEFINITIVE GUIDANCE ON
EXACTLY HOW TO HANDLE THE
SITUATION.
SO STAY TUNED, WE HOPE TO HAVE
SOME GOOD ANSWERS FOR YOU SOON.
>> Kysa: OUT OF
BIG IS THE VIRUS?
AND THEN IN PARENTHESES,
MICRONS.
>> WE CONSIDER CORONAVIRUS, IT
CAN TAKE DIFFERENT SIZES AND
SHAPES.
BUT GENERALLY, Well, WE CONSIDER coronavirus
like some other viruses pleomorphic. IT can take different sizes and shapes.
But generally we consider it a
MODERATELY SIZED VIRUS,
SOMEWHERE BETWEEN 100 AND 150
NANOMETERS.
>> Kysa: Out of
HIGHER RISK FOR SARS?
AND IN PARENTHESES,
HIGH INCIDENCE?
I'M NOT QUITE SURE --
>> DON'T REALLY KNOW THE ANSWER
TO THAT QUESTION.
I THINK WE'LL HAVE TO WAIT FOR
SOME OF THE STUDIES FOR THE
PLACES THAT HAVE THE HIGHEST
NUMBERS OF CASES.
DON'T REALLY KNOW YET.
>> Kysa:
AMBULANCES SERVICES.
SHOULD UTILIZEd NEBULIZERS
BE TAKEN OUT OF USE?
YES, SHOULD UTILIZED NEBULIZERS be
TAKEN OUT OF USE.
>> THEY SHOULD CERTAINLY BE
REPROCESSED AFTER USE ON ANY
PATIENTS.
THOSE ARE NOT THINGS THAT SHOULD
GO FROM ONE PATIENT TO ANOTHER
WITHOUT PROPER CLEANING AND
DISINFECTION. So in the sense that
they’re taken out of use for cleaning and disinfection, yes. But
TAKEN OUT OF USE PERMANENTLY, I
WOULD SAY NO, THERE'S NO
INDICATION THAT THERE'S A NEED
TO DO THAT.
>> Kysa: ARE DISPOSABLE FOOD
TRAYS INDICATED FOR SARS
PATIENTS, EVEN THOUGH THIS IS
NOT PART OF CONTACT PRECAUTIONS?
>> NO, CDC HAS NEVER RECOMMENDED
THE USE OF DISPOSABLE DISHES OR
OTHER UTENSILS FOR PATIENTS WITH
SARS.
>> Kysa: AND THEN FROM
WHAT ARE THE SPECIAL PRECAUTIONS
FOR HANDLING TISSUE SPECIMENS OF
SUSPECTED SARS PATIENTS?
>> AGAIN, I THINK I WOULD REFER
YOU TO OUR WEB SITE.
THERE'S AN EXTENSIVE DOCUMENT
THAT GIVES GUIDANCE FOR HANDLING
AND PROCESSING LABORATORY
SPECIMENS. For THE DETAILED DOCUMENT, I
WOULD SUGGEST THAT YOU VISIT THE
WEB SITE TO GET THAT ANSWER.
>> Kysa: IS IT POSSIBLE TO
STERILIZE N-95 MASKS TO REUSE
THEM, AND TO REUSE THEM AFTER
STERILIZATION?
>> Actually, THAT'S A VERY GOOD
QUESTION.
THEY PROBABLY CAN BE PHYSICALLY
STERILIZED.
BUt IT'S PROBABLY NOT A GOOD
IDEA, BECAUSE IT MIGHT AFFECT
THE INTEGRITY OF THE RESPIRATOR
ITSELF.
AND YOU WOULD NOT WANT TO DO
THAT.
SO WE WOULD ADVISE AGAINST
TRYING TO REPROCESS N-95
RESPIRATORS.
THE REUSABLE RESPIRATORS CAN
CERTAINLY BE PREPROCESSED
THROUGH
DISINFECTIon PROCEDURES, BUT NOT
THE DISPOSABLE ones.
>> Kysa: AND OUT OF
IF SARS IS NOT AIRBORNE, WHY DO
WE NEED TO FIT TEST FOR MASKS
IN A CLINICAL TYPE SETTING?
>> WELL, AGAIN, AS I'VE TRIED TO
INDICATE, WE'RE STILL LEARNING
ABOUT THE MODEs OF TRANSMISSION.
IT'S QUITE POSSIBLE AND PROBABLE
IN MY OPINION, THAT THERE ARE
MULTIPLE MODES OF TRANSMISSION.
ALTHOUGH THE MAJOR MODES ARE
PROBABLY LARGE DROPLET IN
CONTACT.
THERE ARE SETTINGS IN WHICH
WE'RE CONCERNED THAT AIRBORNE
TRANSMISSION CAN TAKE PLACE.
PARTICULARLY SURROUNDING AEROSOL
GENERATING EVENTS.
IN PARTICULAR IN THOSE
SETTINGS THAT WE THINK A FULL
RESPIRATORY PROTECTION PROGRAM
SHOULD BE AVAILABLE.
>> Kysa: Out of
PHYSICIANS AND MEDICAL STUDENTS
FROM AFFECTED AREAS REGARDING
POINT CONTACT?
--
PATIENT-pt-, EXCUSE ME, PATIENT
CONTACT IN THIS COUNTRY?
>> AGAIN, I THINK THEY WOULD
FALL UNDER THE SAME GUIDANCE
THAT WE GIVE ANY HEALTH CARE
WORKER.
IF THEY'VE HAD -- AS LINDA
MENTIONED, IF THEY'VE HAD AN
UNPROTECTED HIGH-RISK EXPOSURE,
UNPROTECTED, THEN WE ARE
RECOMMENDING ACTUALLY THAT THOSE
PATIENTS SHOULD -- THOSE HEALTH
CARE WORKERS SHOULD BE EXCLUDED
FROM DUTY FOR A TEN-DAY PERIOD.
HOWEVER, IN THE ABSENCE OF THAT,
THEY SHOULD BE MONITORING THEMselves
FOR SIGNS AND SYMPTOMS OF
ILLNESS VERY CLOSELY, MEASURE
THEIR TEMPERATURE TWICE DAILY.
But AS LONG AS THEY'RE ASYMPTOMATIC,
THEY SHOULD BE ALLOWED TO WORK.
>> Kysa: OKAY.
AND DR. JERNIGAN, ANOTHER
QUESTION FROM LINDA OUT OF NEW
IT WAS
STATED THERE IS VIRAL
SHEDDING
FOR AS LONG AS 21 DAYS
POST-ILLNESS
ONSET.
THEREFORE,
WHEN IS A SARS
PATIENT
CONSIDERED SARS NEGATIVE
AS IT
RELATES TO THEM BEING A
POTENTIAL
SOURCE FOR CONTINUING
SPREAD,
I THINK IS THE WORD
HERE?
>>
WELL, THIS IS OBVIOUSLY A
VERY
CRITICAL QUESTION.
I
SHOWED THOSE DATA.
AND I THINK THERE ARE A COUPLE
OF CAVEATS
THERE,
NUMBER
ONE, TO REMEMBER THAT those patients who are being treated with steroids which
might INFLUENCE
THE
DURATION OF THE VIRAL
SHEDDING,
AND ALSO, WE DON'T
KNOW WHAT
THAT MEANS FOR
TRANSMISSION.
THAT'S ONE
OF THE CRITICALLY
IMPORTANT
EPIDEMIOLOGIC
QUESTIONS,
WHEN IS THE PERIOD OF
COMMUNICABILITY
after the onset of symptoms.
AND I
DON'T THINK WE KNOW THE
answer TO
THAT question reliably YET.
OUR
GUIDANCE SUGGESTS THAT FOR
PATIENTS
WHO MEET THE CASE
DEFINITION
OF SARS, ISOLATION
PRECAUTIONS
SHOULD BE CONTINUED
FOR A FULL
TEN DAYS FOLLOWING
RESOLUTION
OF FEVER, PROVIDED that
RESPIRATORY
SYMPTOMS ARE ABSENT
OR
RESOLVING.
WE HAVE NO
DATA SO FAR TO
SUGGEST
THAT THAT'S
INSUFFICIENT.
BUT WE'RE
LOOKING AT THIS VERY
CAREFULLY.
AS SOON AS
WE GET MORE DATA THAT
SUGGESTS
THAT IT'S NOT, WE WILL
COMMUNICATE
THAT VERY RAPIDLY.
RIGHT NOW,
WE'RE SITTING TIGHT
WITH THAT
RECOMMENDATION.
AND
FOLLOWING VERY CLOSELY THE
SITUATION.
>>
Kysa: OKAY.
AND PATTY
OUT OF
WANTS TO
KNOW, IS THERE A
DIFFERENCE
BETWEEN TREATMENT
PROTOCOL
BETWEEN THE UNITED
>>
WE DON'T HAVE A
WITH WHAT
TREATMENT REGIMENS ARE
BEING USED
IN
IN
PUBLISHED
THEIR USE OF A
COMBINATION
OF RIBAVIRIN, PLUS
STEROIDS.
There are SOME ANECDOTAL REPORTS FROM THAT
THAT THERE
MIGHT BE SOME BENEFIT
TO
PATIENTS.
BUT AGAIN,
WE THINK THAT THOSE
DATA ARE
DIFFICULT TO INTERPRET
IN THE
ABSENCE OF A CONTROLLED
TRIAL.
IN THE
UNITED STATES, OF COURSE,
WE'VE HAD
VERY FEW PATIENTS IN
GENERAL,
RIBAVIRIN and/or
steroids have NOT BEEN USED
WIDELY in
our patients.
>>
Kysa: AND JUST TO LET
EVERYONE KNOW,
WE ARE GOING TO
RUN JUST A
LITTLE LONG TODAY,
BECAUSE WE
HAVE BEEN GETTING SO
MANY
QUESTIONS IN from VIEWERS TODAY.
SO WE'LL
CONTINUE RIGHT ALONG.
THIS ONE
IS OUT OF
WHEN IS A
PERSON WITH SARS
CONSIDERED
NO LONGER -- NO
LONGER
CONSIDERED INFECTIOUS?
>> I
THINK AS I SAID BEFORE, OUR
POLICY IS
THAT FOR THOSE THAT
MEET THE
CASE DEFINITION, FOR
TEN DAYS
FOLLOWING RESOLUTION OF
FEVER,
PRESUMING THAT THE
RESPIRATORY
SYMPTOMS ARE either ABSENT
OR
RESOLVING.
>>
Kysa: AND THIS QUESTION OUT
OF
DOES
CDC RECOMMEND TRIAGE IN THE
E.R.
AND URGENT
ITS
SUSPECTED SARS PATIENTS?
>>
YES, WE DO RECOMMEND TRIAGE.
IT'S
PART OF AN OUTPATIENT
PROCEDURE
AN E.R. PROCEDURE TO
ASSESS
THE STATUS OF PATIENTS
WHO ARE
PRESENTING WITH
SYMPTOMS.
AND WE
ENCOURAGE SOME KIND OF
VERBAL
SIGNAGE TO ALERT PATIENTS
THAT
THEY SHOULD REPORT SIGNS
AND
SYMPTOMS.
AND
THAT THEY USE A MASK IF THEY
DO HAVE
RESPIRATORY SYMPTOMS,
AND TO
SEGREGATE THOSE PATIENTS
INTO AN
AREA WHERE THEY WILL NOT
HAVE CONTACT
WITH OTHERS WHO MAY
BE IN
THAT AREA.
BUT
YES, INDEED, TRIAGE SHOULD
OCCUR
IN THOSE SETTINGS.
>> Kysa: AND A VIEWER OUT OF
THE ALCOHOL GELS AS EFFECTIVE AS
USING, MS. CHIARELLO, SOAP AND
WATER?
>> As far as we know, THE ALCOHOL
GELS SHOULD BE equally AS
EFFECTIVE AS SOAP AND WATER.
>> Kysa: WOULD YOU CONSIDER
DENTAL PROCEDURES AS AEROSOL
GENERATING
PROCEDURES THAT
WARRANT
SPECIAL PRECAUTIONS BY
DENTAL
HEALTH CARE WORKERS?
>>
I THINK IT'S A GOOD QUESTION.
I THINK
THE POTENTIAL is THERE;
HOWEVER,
I WOULD BACK UP AND SAY
IT'S
PROBABLY A GOOD IDEA TO
DEFER
ANY ELECTIVE DENTAL
TREATMENT
IN A PATIENT WHO YOU
SUSPECT
HAS SARS.
SO
HOPEFULLY THAT SHOULD BE A
PRETTY
RARE OCCURRENCE.
>>
Kysa: THIS IS ANOTHER DENTAL
RELATED QUESTION OUT OF
HAVE DENTAL HEALTH CARE WORKERS
EXPERIENCED SARS INFECTION
FOLLOWING DENTAL PROCEDURES ON
SARS INFECTED PEOPLE?
>> I'M NOT AWARE OF ANY
INFECTIONS IN DENTAL WORKERS.
>> Kysa: AND NOW, DONNA OUT OF
ON NPR THAT IN
IDENTIFIED THE VIRUS IN FEces.
CAN THE panel comment on public health
measures to contain THIS TYPE OF
TRANSMISSION?’s CERTAINLY
IS THE CASE.
DR. JERNIGAN SHOWED INDICATION
THAT THE VIRUS WAS PRESENT IN
BOTH feces AND URINE.
CLEARLY THAT MEANS THAT ADEQUATE
HYGIENE IS IMPORTANT TO MAKE
SURE THAT THAT
SOURCE OF VIRUS
IS CONTROLLED.
I DON'T THINK WE HAVE A MAJOR
PROBLEM HERE IN THE UNITED
STATES.
BUT IN SOME DEVELOPING PARTS OF
THE WORLD, THAT MAY IN FACT BE A
SOURCE OF GREAT CONCERN.
>> Kysa: LOOKS LIKE THIS ONE'S
OUT OF
IS IT OKAY TO GIVE NEBULIZER
TREATMENTS AND WHAT MEDICATION
SHOULD BE USED IN THE
NEBULIZER?
>> WE'RE CURRENTLY RECOMMENDING
AGAINST nebulization UNLESS IT'S
MEDICALLY
NECESSARY.
MAYBE DR. JERNIGAN HAS A COMMENT
IN TERMS OF MEDICATION.
BUT IN TERMS OF THE PROCEDURE,
WE WOULD DISCOURAGE IT UNLESS IT
WAS MEDICALLY NECESSARY.
IF IT IS MEDICALLY NECESSARY, TO
DO IT IN AN ENVIRONMENT, in a
PROTECTED ENVIRONMENT, a NEGATIVE
PRESSURE ROOM WOULD BE IDEAL
WITH HEALTH CARE PERSONNEL
APPROPRIATELY GARBED IN GOWN AND
GLOVES AND RESPIRATORY
PROTECTION AND GOGGLES AS WELL.
>> Kysa: DR. JERNIGAN, THIS
PERSON SAYS THAT YOU STATED THAT
ANY DETERGENT SHOULD BE
SUFFICIENT TO KILL THE ORGANISM.
WAS THIS A CORRECT STATEMENT, OR
DID YOU MEAN ANY DISINFECTANT?
>> WELL, WE THINK THAT BEING A
lipid envelope VIRUS, WE HAVE NO
REASON TO SUSPECT HOUSEHOLD
DETERGENTS SHOULDN'T BE
EFFECTIVE IN CONTROLLING THIS
VIRUS.
AND I ALSO SAID DISINFECTANTS
AS WELL.
WE have HEARD some REPORTS FROM SOME LABS
AROUND THE WORLD THAT have QUESTIONED
THAT.
WE THINK THE DATA ARE
SURPRISING.
AND WE THINK THEY NEED TO BE
CONFIRMED IN OTHER EXPERIMENTS.
AND WE ARE IN THE PROCESS OF
PURSUING SOME OF THOSE ANSWERS.
I DON'T KNOW IF JIM OR, DEAN, IF
YOU HAVE ANY OTHER THOUGHTS ON
THAT.
>> WELL, I THINK THE CONSENSUS
IS THAT, YOU KNOW, ESTABLISHED
DISINFECTANTS WILL likely WORK WELL
WITH THIS PARTICULAR VIRUS.
BUT again, THOSE STUDIES ARE BEING DONE
AND WE'LL KNOW more IN THE NEAR
FUTURE.
>> Kysa: It’s such a new disease
and there’s so much to learn. The next question is out of
DO PEDIATRIC PATIENTS HAVE A
DIFFERENT TEMPERATURE THRESHOLD
THAN 100.4?
AND THEN THE SECOND QUESTION IS,
Is TYLENOL PREFERRED OVER
ASPIRIN BECAUSE OF ASPIRIN'S
POTENTIAL ACTION ON P-38?
>> SO FAR WE HAVE NO DISTINCTION
BETWEEN THE TEMPERATURE
THRESHOLD FOR ADULTS AND
CHILDREN WITH REGARD TO our
CASE DEFINITION.
I'M NOT A PEDIATRICIAN.
AND I THINK IN GENERAL WE PREFER
TYLENOL OVER ASPIRIN FOR FEBRILE
IN THAT AGE GROUP. But
I'M A LITTLE FAR AFIELD FROM MY
AREA OF EXPERTISE IN THAT
REGARD.
>> Kysa: ALL RIGHT.
ALSO FROM
THAT INFECTION WITH MILDER
CORONAVIRUS CONFERS IMMUNITY FOR
SARS?
>> I THINK, AGAIN, WE DON'T HAVE
AN ANSWER FOR THAT.
BUT I THINK THE EVIDENCE
SUGGESTS THAT THE SEROLOGICAL
EVIDENCE SUGGESTS THAT THERE'S
NO ANTIBODIES TO SARS.
WE'RE CLEARLY, MOST OF US,
INFECTED WITH THE HUMAN
CORONAVIRUSES, HENCE, IT'S
LIKELY THAT THERE WOULD BE NO
PROTECTION FROM HUMAN
CORONAVIRUSES FOR THE SARS
AGENT.
>> Kysa: OUT OF
HAVE UNDERSTOOD THE INFLUENZA
VACCINES ARE MADE IN RESPONSE TO
THE PATTERN OF INFLUENZA IN
WILL THIS HAVE ANY BEARING ON
CORONAVIRUS?
COULD WE EXPECT YOU, AS THE
UNITED STATES -- A
>> EVERY YEAR THE CDC
PARTICIPATES IN A GLOBAL NETWORK
OF LABORATORIES THAT MONITOR
TRANSMISSION OF INFLUENZA AROUND
THE WORLD.
AND TWICE A YEAR, CDC AND OTHER
EXPERTS GET TOGETHER AT THE
WORLD HEALTH ORGANIZATION AND
DECIDE UPON THE COMPOSITION OF
THAT YEAR'S INFLUENZA VACCINE.
IN SEPTEMBER, WE'LL MEET TO
DISCUSS THE VACCINE FOR THE
SOUTHERN HEMISPHERE, AND IN
FEBRUARY WE WILL FOR THE
NORTHERN HEMISPHERE.
I DON'T THINK THAT THERE'S ANY
REASON TO SUGGEST THAT THE
INCIDENCE OF INFLUENZA WILL BE
AFFECTED
THE INCIDENCE OF THE SARS
OUTBREAK THAT WE'RE CURRENTLY
EXPERIENCING.
>> Kysa: DR. LE DUC, THIS IS AN
INTERESTING QUESTION.
WHAT IS THE MODE OF DEATH FROM
SARS, RESPIRATORY FAILURE,
MULTI-ORGAN FAILURE, second-degree
INFECTION, OR OTHER?
>> I THINK THAT MOST PATIENTS
DIE OF ARDS.
BUT PERHAPS DR. JERNIGAN CAN
GIVE US MORE a little more DETAIL.
>> I THINK THAT'S RIGHT.
OF COURSE, WE HAVEN'T HAD ANY
DIRECT EXPERIENCE with DEATHs
FROM SARS HERE IN THE UNITED
STATES.
BUT FROM COMMUNICATION WITH OUR
INTERNATIONAL PARTNERS AND FROM
WHAT WE'VE SEEN IN THE
LITERATURE, IT WOULD APPEAR THAT
THE MECHANISM IS BASICALLY
DIFFICULTY OXYGENATING THESE
PATIENTS, AND ARDS AND SEVERE
RESPIRATORY FAILURE.
MULTI-ORGAN SYSTEM FAILURE HAS
BEEN REPORTED IN A FEW PATIENTS
but not all, AND I THINK THE DIFFICULTY
OXYGENATING PATIENTS HAS BEEN
THE MAJOR MODE OF DEATH.
>> Kysa: OUT OF
QUESTION IS, IS A NASAL
CONSIDERED AN AEROSOL GENERATING
PROCEDURE?
>> AGAIN, I THINK SOME JUDGMENT
NEEDS TO BE EXERCISED.
THAT'S NOT CURRENTLY INCLUDED IN
OUR SORT OF LIST OF WHAT WE
CONSIDER AEROSOL GENERATING
PROCEDURES.
BUT, YOU KNOW, AFTER WE GET MORE
INFORMATION, WE MAY NEED TO
RECONSIDER THAT.
BUT CURRENTLY, NOT.
>> LET ME JUST ADD THAT, NASAL
WASHES HAVE BEEN A SOURCE OF
VIRUS IN THE some of the SPECIMENS WE'RE
TESTING.
SO IF A CLINICIAN SUSPECTS A
PATIENT WITH SARS and IS TAKING A
NASAL
PROTECTIVE MEASURES WE'VE BEEN
DISCUSSING SHOULD BE
>> Kysa: THIS CALLER WANTS TO
KNOW, GRADUATION IS NEAR.
WHAT ABOUT VISITORS FROM
OR OTHER AFFECTED AREAS?
WHAT ABOUT THEM?
>> AGAIN, WE HAVE GUIDANCE ON
OUR WEB SITE ON WHAT SHOULD BE
DONE.
I THINK IT'S IMPORTANT THAT A
PERSON WHO'S VISITING FROM AN
EXPOSED -- FROM AN AREA
ASSOCIATED WITH SARS
TRANSMISSION SHOULD MONITOR
THEMSELVES VERY CLOSELY FOR A
PERIOD OF TEN DAYS AFTER LEAVING
THE EXPOSED AREA, MEASURE THEIR
TEMPERATURE TWICE A DAY,
AND AT THE FIRST SIGN OF ANY
FEVER OR RESPIRATORY SYMPTOM OR
ILLNESS, SHOULD CONTACT A HEALTH
CARE PROVIDER,
AGAIN, EMPHASIZING THAT IF
THEY'RE PRESENTING FOR
EVALUATION, THEY SHOULD NOTIFY
THE HEALTH CARE PROVIDER AHEAD
OF TIME, IN ADVANCE, THAT YOU'RE
A PERSON WHO MAY HAVE BEEN INTO
A SARS-EXPOSED AREA AND YOU HAVE
A RESPIRATORY ILLNESS OR FEVER,
SO THE PREPARATIONS CAN BE MADE
TO -- FOR ISOLATION WHEN ONE
PRESENTS TO THE HEALTH CARE
SETTING.
>> Kysa: THIS QUESTION OUT OF
IT SAYS, WE TALK ABOUT
ETCETERA.
IS THERE EVIDENCE IN
AND
PRECAUTIONS THAT
SHOULD TAKE WHEN TRAVELING TO
THESE DIFFERENT AREAS?
>> I THINK THE WORLD HEALTH
ORGANIZATION HAS A VERY ACCURATE
AND UP-TO-DATE WEB SITE THAT
DOCUMENTS THE PRESENCE OF CASES
AROUND THE WORLD.
AND TRAVELERS MAY WISH TO CHECK
THAT WEB SITE.
AND I THINK WE'LL GIVE THAT TO
YOU BEFORE THE END OF THE
DISCUSSION.
>> Kysa: I'LL JUST GIVE IT OUT
QUICKLY RIGHT NOW.
IT IS WWW..WHO.INT, AND then the web
address for CDC is
WWW.CDC.GOV.
NEXT QUESTION OUT OF
SUSPECTED SARS PATIENT IN A
NEGATIVE AIR PRESSURE ROOM?
>> THE ANSWER IS YES.
IF THE PATIENT NEEDS -- REQUIRES
HOSPITALIZATION, THEN A NEGATIVE
PRESSURE ROOM IS INDICATED UNTIL
THAT PATIENT -- THE DIAGNOSIS OF
SARS CAN BE RULED OUT.
WE RECOMMEND AIRBORNE
PRECAUTIONS FOR ANYONE WITH A
SUSPECT SARS.
AND SO IF THEY'RE HOSPITALIZED,
INDEED, THEY WOULD BE PUT INTO
THAT KIND OF ENVIRONMENT.
>> Kysa: AND I THINK WE'VE
ALREADY KIND OF TOUCHED ON THIS.
OUT OF
IT SAYS, CORONAVIRUS, OR IS
CORONAVIRUS, OR HAS IT BEEN
DETECTED IN STOOL and URINE FROM
SARS PATIENTS? (yes)
>> Kysa: OUT OF
IS BEING USED FOR SARS LAB
DIAGNOSIS.
WHAT OTHER -- WHAT ELSE IS
NEEDED TO RULE OUT EXPOSURE TO
OTHER CORONAVIRUSES?
>> I THINK THE QUESTION IS, WHAT
TITER.
BECAUSE SARS coronavirus is SO RARE IN this
POPULATION NOW, in our population now,
ANY DETECTABLE
ANTIBODY WOULD BE CONSIDERED A
POSITIVE.
SO YOU DON'T HAVE TO MEASURE AN
AMOUNT ABOVE A CERTAIN BASELINE
LEVEL AT THIS POINT.
>> Kysa: OKAY.
ALL RIGHTY.
DO WE HAVE SOME MORE QUESTIONS?
I HAVE A WHOLE STACK HERE.
AGAIN, I WANT TO GIVE OUT THE
WEB SITES FOR THOSE OF YOU
WATCHING.
IT'S WWW.WHO.INT FOR THE WORLD
HEALTH ORGANIZATION.
AND THEN THE WEB ADDRESS FOR CDC
IS WWW.CDC.GOV.
QUESTION OUT OF
SARS BEING LOOKED AT AS A
POTENTIAL BIOTERRORIST AGENT?
>> THAT'S A VERY GOOD QUESTION.
AND CERTAINLY WAS IN OUR
THINKING AS THIS OUTBREAK
ORIGINATED
AND WE LEARNED MORE AND MORE
ABOUT IT.
THE INFORMATION THAT DR. ERDMAN
HAS PRESENTED ABOUT THE VERY,
VERY UNIQUE SEQUENCE OF THIS
VIRUS WOULD LEAD US TO BELIEVE
THAT it IS A NATURALLY OCCURRING
VIRUS UNLIKE ANY OTHER VIRUS
THAT'S KNOWN TO SCIENCE, AND
CONSEQUENTLY, ALMOST CERTAINLY
NOT MAN-MADE.
>> Kysa: NEXT QUESTION.
HOW EFFECTIVE ARE CORONAVIRUS
VACCINES IN ANIMALS?
>> I'M NOT FAMILIAR WITH THE
VETERINARY WORLD.
THERE ARE NO CORONAVIRUS
VACCINES FOR HUMANS, BECAUSE, they’re
very mild infections.
CERTAINLY THERE'S A LOT OF
ONGOING RESEARCH TO LOOK AT THE
POTENTIAL FOR VACCINES FOR THIS
AGENT IN THE FUTURE.
>> Kysa: AND THEN OUT OF
KNOW, HOW DO THE CASE FATALITY
RATES FOR SARS COMPARE TO THAT
OF INFLUENZA?
>> THE CASE FATALITY RATE FOR
SARS SEEMS TO BE CREEPING UP AS
WE LEARN MORE ABOUT THE DISEASE,
WE HAVE MORE DATA TO WORK FROM.
THE WORLD HEALTH ORGANIZATION
HAS RECENTLY PUBLISHED SOME
ESTIMATES OF CASE FATALITY
RATIO THAT SUGGESTED THOSE IN
THE OLDER AGE GROUPS, ABOVE 65,
ARE AT ESPECIALLY HIGH RISK OF
DYING FROM THE INFECTION. And
CONVERSELY, THOSE IN THE VERY
YOUNG AGE GROUPS ARE, WE'VE SEEN
MORTALITY VERY, VERY RARELY.
AND IT'S A GRADATION ON UP.
I THINK IN GENERAL THE MORTALITY
RATE IN INFLUENZA IS LESS THAN
WHAT WE'RE NOW ESTIMATING
OVERALL FOR SARS INFECTIONS.
>> Kysa: AND THEN A QUESTION OUT
OF
WHAT ARE TRUE SPECIAL
PRECAUTIONS FOR HANDLING OF
TISSUE SPECIMENS FROM SUSPECTED
SARS PATIENTS?
>> AGAIN, AS WE MENTIONED BEFORE
I WOULD ENCOURAGE YOU TO CHECK
THE WEB SITE.
THERE'S A SPECIFIC GUIDANCE
DOCUMENT ON HANDLING OF
LABORATORY SPECIMENS.
IT'S QUITE DETAILED.
>> Kysa: WE'RE RUNNING OUT OF
QUESTIONS.
I THINK THINGS ARE KIND OF
SLOWING DOWN.
AND UNFORTUNATELY, THAT'S ALL
THE TIME WE HAVE FOR YOUR
QUESTIONS.
IF YOU HAVE ANY ADDITIONAL
QUESTIONS THAT YOU'D LIKE TO
HAVE ANSWERED, PLEASE USE THE
CDC CLINICIANS INFORMATION LINE,
AND THAT NUMBER TO CALL IS
1-877-554-4625.
AGAIN, THAT NUMBER,
1-877-554-4625.
FOR OTHER QUESTIONS, REMEMBER TO
VISIT THE CDC AND WORLD
HEALTH ORGANIZATION WEB SITEs for the
very latest information on SARS.
WE'LL REPEAT THOSE WEB
ADDRESSES.
FIRST THE WORLD HEALTH
ORGANIZATION, WWW.WHO.INT.
AND THEN HERE AT CDC, WEB SITE
IS WWW.CDC.GOV.
PARTICIPANTS OF THIS BROADCAST
ARE ENCOURAGED BUT NOT REQUIRED
TO REGISTER AND EVALUATE THE
PROGRAM ON THE CDC TRAINING AND
CONTINUING EDUCATION ONLINE
SYSTEM.
AND THAT ADDRESS IS
WWW.PHPPO.CDC.GOV/PHTNONLINE.
PARTICIPANT REGISTRATION AND
EVALUATION WILL BEGIN MAY 8th,
2003, AND END ON JUNE THE 8th,
2003.
AND HERE ARE THE COURSE NUMBERS
THAT YOU'LL NEED.
THE NUMBER FOR THE SATELLITE
BROADCAST.
SB 0130.
AND THEN FOR THE WEB CAST, THE
NUMBER, WC 0030.
QUESTIONS
ABOUT REGISTRATION SHOULD BE
DIRECTED TO 800-41-TRAIN, OR
404-639-1292.
OR E-MAIL CE AT CDC.GOV.
WHEN E-MAILING A REQUEST, PLEASE
INDICATE SARS 2, THAT IS THE
NUMBER 2, IN THE SUBJECT LINE.
AND BEFORE WE WRAP UP, I WANT TO
MAKE SURE THAT CLINICIANS WHO
WATCH OUR PROGRAM ARE AWARE OF
THE CLINICIANS' REGISTRY.
CLINICIANS WHO REGISTER AT THIS
SITE WILL RECEIVE ALERTS AND
UPDATES ON PUBLIC HEALTH THREATS
AND INFORMATION ON CDC SPONSORED
TRAINING.
TO JOIN THIS REGISTRY YOU CAN
VISIT ANOTHER WEB SITE,
WWW.BT.CDC.GOV/CLINREG.
WE'D LIKE TO INVITE YOU TO JOIN
US FOR OUR NEXT BROADCAST, WHICH
IS COMMUNITY PREPAREDNESS FOR
SEVERE ACUTE RESPIRATORY
SYNDROME -- SARS.
THAT'S GOING TO BE ON TUESDAY,
MAY 20th FROM
I'M KYSA DANIELS.
IT CERTAINLY HAS BEEN MY
PLEASURE BEING YOUR MODERATOR
FOR THIS BROADCAST.
THANK YOU AGAIN TO DR. JERNIGAN,
TO LINDA CHIARELLO, TO
DR. ERDMAN, AND DR. JIM LE DUC.
WE APPRECIATE YOUR EXPERTISE AND
TIME.
GOOD-BYE from ALL OF US FROM US
HERE AT THE CENTERS FOR DISEASE
CONTROL AND PREVENTION HERE IN
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