Severe Acute
Respiratory Syndrome (SARS) |
This
advisory provides updated information and recommendations following
recent reports of cases of severe acute respiratory syndrome (SARS)
in Guangdong Province, China, and human cases of influenza
A(H5N1) virus infections in Vietnam. No travel alerts or advisories
to these regions have been issued by the Centers for Disease
Control and Prevention (CDC), but increased vigilance is advised
for ill persons traveling to the United States from Guangdong
Province and Vietnam, Japan, and South Korea.
Severe Acute Respiratory Syndrome
Recent SARS Cases in China
On January
13, 2004, the Chinese Ministry of Health (MOH) and the World Health
Organization (WHO) reported a new suspect case SARS in a 35-year-old
man living in Guangdong Province, China. This case is the third recent
report of suspected or confirmed SARS in patients in southern China.
No link has been established at present between the confirmed case and
the two recent suspect SARS cases, and the source of exposure for all three
cases is unclear.
On January
5, 2004, Chinese and WHO authorities announced that laboratory results
confirmed evidence of SARS-associated coronavirus infection (SARS-CoV)
in a 32-year-old man in Guangdong Province who had become ill on
December 16, 2003. On January 8, 2004, a suspect case of SARS was
reported in a 20-year-old woman who works in a restaurant in Guangdong
Province and had onset of illness on December 25, 2003. On January
12, 2004, a suspect case of SARS was reported in a 35-year-old man
from Guangdong Province who had onset of illness on December 31,
2003, and was admitted to Guangdong People's Hospital and placed in isolation
on January 6. All three patients are reported to be doing well, and
no signs or symptoms of SARS-like illness have been reported among their
identified contacts to date. Details on the clinical features and laboratory
results of the 2 suspect SARS cases are not yet available.
Recommended U.S. SARS Control Measures
In light of these reports, the CDC is recommending that U.S. physicians
maintain a greater index of suspicion of SARS in patients who require hospitalization
for radiographically confirmed pneumonia or acute respiratory distress syndrome
(ARDS) AND who have a history of travel to Guangdong Province (or close contact
with an ill person with a history of recent travel to Guangdong Province)
in the 10 days before onset of symptoms. When such patients are identified,
the following actions should be taken:
- Patients should immediately be placed in appropriate isolation
precautions for SARS (i.e., contact and airborne precautions)
- Patients should promptly be reported to the state or local health
department
- Patients
should promptly be tested for evidence of SARS-CoV infection as
part of the diagnostic evaluation (see Appendix 2 "Updated Guidelines
for Collecting Specimens from Potential SARS Patients," in the CDC
document, "In the Absence of SARS-CoV Transmission Worldwide: Guidance
for Surveillance, Clinical and Laboratory Evaluation, and Reporting" at www.cdc.gov/ncidod/sars/absenceofsars.htm
- The
health department should identify, evaluate, and monitor relevant
contacts of the patient, as indicated. In particular, the
health status of household contacts or persons who provided care
to symptomatic patients should be assessed.
In addition, CDC continues to recommend that health care providers and public
health officials identify and report patients who require hospitalization
for radiographically confirmed pneumonia or ARDS without identifiable etiology
AND who have one of the following risk factors in the 10 days before the
onset of illness:
- Travel
to mainland China, Hong Kong, or Taiwan, or close contact with
an ill person with a history of recent travel to one of these areas,
OR
- Employment in an occupation associated with a risk for SARS-CoV
exposure (e.g., health care worker with direct patient contact; worker
in a laboratory that contains live SARS-CoV), OR
- Part of a cluster of cases of atypical pneumonia without an alternative
diagnosis.
Diagnostic testing for SARS should be considered in such patients, as described
in the guidelines at www.cdc.gov/ncidod/sars/absenceofsars.htm .
Infection control practitioners and other health care personnel should also
be alert for clusters of pneumonia among two or more health care workers
who work in the same facility.
Advice for Travelers (SARS)
At this time,
WHO and CDC have not issued any alerts or advisories for travel to
China (www.cdc.gov/ncidod/sars/travel_alertadvisory.htm ). Previous
SARS research has shown that SARS can be controlled and contained
through early detection, isolation of suspect cases, and tracing of their
contacts.
On the basis
of limited available data, it would be prudent for travelers to China
to avoid visiting live food markets and avoid direct contact with civets
and other wildlife from these markets. Although there is no evidence that
direct contact with civets or other wild animals from live food markets
has led to cases of SARS, viruses very similar to SARS-CoV-the virus that
causes SARS-have been found in these animals. In addition, some persons working
with these animals have evidence of infection with SARS-CoV or a very
similar virus.
U.S.
Bans Importation of Civet Cats
On January
13, 2004, the Department of Health and Human Services (HHS) announced an
immediate embargo on the importation of civets to the United States ( http://www.cdc.gov/ncidod/sars/civet_ban_exec_order.htm ).
These small animals have been identified as a possible link to SARS
transmission in China . The embargo, which applies to dead and live civets
as well as civet products, will remain in place until further notice. Civet
products that have been processed to render them noninfectious, such as
fully taxidermied animals and finished trophies, are not included in the
embargo. The ban does not apply to civet cats approved by CDC for importation
for educational or scientific purposes.
More Information About SARS
For more information
about current U.S. SARS control guidelines, see the CDC document, "In the
Absence of SARS-CoV Transmission Worldwide: Guidance for Surveillance,
Clinical and Laboratory Evaluation, and Reporting" at www.cdc.gov/ncidod/sars/absenceofsars.htm .
The document is part of CDC's draft Public Health Guidance for Community-Level
Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) www.cdc.gov/ncidod/sars/sarsprepplan.htm .
For additional
information about the reported SARS cases in China, see the Web sites
of CDC (www.cdc.gov/sars)
and WHO (www.who.int/en/).
Influenza A (H5N1) Virus Infections
Recent Influenza A (H5N1) Cases
Since the end of October 2003, 14 persons (13 children and 1 adult) in Vietnam
have been admitted from surrounding provinces to hospitals in Hanoi for severe
respiratory illness. Among the 14 patients, three (2 children and 1 adult)
have had avian influenza A (H5N1) virus infections confirmed by testing conducted
at the National Institute of Hygiene and Epidemiology in Hanoi and in Hong
Kong. Twelve of the patients, including 11 children and the mother of one
of the deceased children, have died.
Influenza A
(H5N1) viruses normally circulate among wild birds but can infect poultry
and rarely have infected people in the past. In 1997, 18 persons in Hong
Kong were hospitalized because of influenza A (H5N1) infections and six
of them died. In 2003, two residents of Hong Kong who traveled to China
developed influenza A (H5N1) virus infections and one of them died.
In Vietnam, large outbreaks of influenza A (H5N1) have been reported among
poultry in the southern and northern regions of the country. WHO has reported
that t he H5N1 strain implicated in the outbreak has now been partially
sequenced. All genes are of avian origin, indicating that the virus that
caused death in the three confirmed cases had not yet acquired human genes.
The acquisition of human genes increases the likelihood that a virus of
avian origin can be readily transmitted from one human to another.
Staff from
CDC will travel to Vietnam to work with WHO and Vietnam's human and animal
health authorities to evaluate the situation, including patterns of transmission
of the influenza A (H5N1) viruses.
During December
2003, an outbreak of avian influenza A (H5N1) was reported among poultry
in South Korea. Earlier this week, Japan reported the deaths of 6,000 chickens
on a single farm in the western part of Honshu due to influenza A (H5N1)
virus infection. No human cases of infection with the avian influenza virus
have been reported in either of these outbreaks.
Enhanced U.S. Influenza Surveillance
At this time, CDC recommends enhanced surveillance efforts by state and
local health departments, hospitals, and clinicians to identify patients
who have been hospitalized with unexplained pneumonia, ARDS, or severe respiratory
illness AND who have traveled to Vietnam , South Korea , and Japan within
10 days from onset of symptoms
All such patients
should be tested for influenza virus infection; these tests should
include viral culture of nasopharyngeal and throat swabs. All
influenza A viruses should be subtyped, and those that cannot be identified
as H3 or H1 viruses should be sent immediately to CDC for testing for
influenza A (H5N1).
CDC will make
additional recommendations on enhanced surveillance if influenza
A (H5N1) activity continues to evolve.
SARS and Influenza A(H5N1)
There is considerable
potential for the clinical presentation and travel history of persons
with either SARS or influenza A (H5N1) infection to overlap. Therefore,
the following actions should be taken:
- Influenza
A infection should be considered in the differential diagnosis
when evaluating a SARS patient.
- Laboratories
should make subtyping of influenza A viruses isolated from potential
SARS cases a priority.
- The
laboratory should immediately notify the CDC's Influenza Branch
if any influenza A virus cannot be subtyped.
More Information About Influenza
For further details about
the reported cases of influenza A(H5N1) in Vietnam , see the WHO
Web site www.who.int/en/ .
Additional information about influenza is available on the CDC Web
site at www.cdc.gov/flu .
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