A. Surveillance
in the Absence of Person-to-Person Transmission of SARS-Cov in the
World
Objective: Establish surveillance aimed at early detection
of cases and clusters of severe unexplained respiratory infections (i.e.,
pneumonia) that might signal the re-emergence of SARS-CoV.
Continued vigilance is critical to ensure the rapid recognition and
appropriate management of SARS patients if person-to-person SARS-CoV
transmission recurs. In the absence of known areas with SARS-CoV transmission,
the likelihood that a patient with fever or respiratory symptoms has
SARS-CoV disease will be exceedingly low unless the patient has both
typical clinical findings and some accompanying epidemiologic evidence
that raises the suspicion of exposure to SARS-CoV. Therefore, U.S. surveillance
efforts should focus on specific clinical syndromes (i.e., cases of pneumonia
requiring hospitalization) in groups likely to be first affected by the
re-emergence of SARS-CoV (e.g., travelers to areas previously affected
with SARS-CoV; healthcare workers).
The 2003 SARS-CoV outbreak likely originated in mainland China, and
neighboring areas such as Taiwan and Hong Kong are thought to be at higher
risk due to the large volume of travelers from mainland China. Although
less likely, SARS-CoV may also reappear from other previously affected
areas. Therefore, clinicians should obtain a complete travel history.
If clinicians have concerns about the possibility of SARS-CoV disease
in a patient with a history of travel to other previously affected areas
(e.g., while traveling abroad, had close contact with another person
with pneumonia of unknown etiology or spent time in a hospital in which
patients with acute respiratory disease were treated), they should contact
the health department.
In the absence of SARS-CoV transmission in the world, the screening
of persons requiring hospitalization for radiographically confirmed pneumonia
for risk factors suggesting SARS-CoV exposure should be limited to adults,
unless there are special circumstances that make the clinician and public
health personnel consider a child to be of potentially high risk for
having SARS-CoV disease. During the 2003 global outbreaks, infants and
children accounted for only a small percentage of SARS cases and had
a much milder disease and better outcome than adults. Although information
on SARS-CoV disease in pediatric patients is limited, the role of children
in transmission is likely much less significant than the role of adults.
Activities:
Healthcare providers
- Consider
SARS-CoV disease in patients who require hospitalization for radiographically
confirmed pneumonia (or acute respiratory distress syndrome) of unknown
etiology and who have one of the following
risk factors in the 10 days before illness onset:
- Travel
to mainland China, Hong Kong or Taiwan, or close contact1 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.,
healthcare worker with direct patient contact; worker in a laboratory
that contains live SARS-CoV2), or
- Part
of a cluster of cases of atypical pneumonia without an alternative
diagnosis
- Use
SARS-CoV testing judiciously and in consultation with local or state
public health officials, given that: 1) the positive predictive value
of a positive laboratory test in the absence of SARS-CoV transmission
is extremely low, and 2) false-positive tests may generate tremendous
anxiety and concern and expend valuable public health resources.
- Be alert
for clusters of unexplained pneumonia among two or more healthcare
workers who work in the same facility.
- Report
to the state or local health department:
- All
persons requiring hospitalization for radiographically confirmed pneumonia
who report at least one of the three risk factors listed above
- Any
clusters of unexplained pneumonia requiring hospitalization, especially
among healthcare workers
- Any
positive SARS-CoV test result (requires immediate notification of the
health department by telephone).
Activities:
State and local health departments
- Disseminate
surveillance guidelines regarding timely recognition, evaluation, and
reporting of possible SARS-CoV cases to healthcare providers, particularly
triage, emergency department, and hospital-based providers.
- Establish
a surveillance system to receive reports of:
- Persons
who require hospitalization for radiographically confirmed pneumonia
and who are found to be at greater risk for SARS-CoV disease based
on the provider-based screening described above,
- Clusters
of persons with unexplained pneumonia, and
- Positive
SARS-CoV test results.
- Review
and obtain information needed to assess reported pneumonia cases and
clusters for the likelihood of SARS-CoV disease. Considerations that
increase the likelihood of SARS-CoV disease include:
- Illness
onset dates grouped within a 10-day period
- Ill
travelers who had contact with healthcare settings or persons hospitalized
for unexplained respiratory infection while abroad and within 10 days
of illness onset
- Clusters
of pneumonia among any group of persons for whom alternative diagnoses
have been reliably excluded or clusters in which one case is linked
to travel to a previously affected area or to an ill healthcare worker
- Review
reports of persons who are hospitalized for pneumonia and are at increased
risk for SARS-CoV disease to ensure that:
- Consult
CDC as needed about cases or clusters of special concern.
- Report
to CDC any positive SARS-CoV test results.
- Inform
CDC of other cases or clusters of pneumonia that are of particular
concern by calling 770-488-7100.
Activities:
CDC
- Provide
guidance to health departments, hospitals, and healthcare providers
on SARS surveillance.
- Assist
state and local health departments in the development of an electronic
reporting system and related forms to facilitate uniform reporting.
- Assist
states, as requested, in investigations of cases and clusters of
persons with possible SARS-CoV disease.
- Collect
and review reports of pneumonia requiring hospitalization in travelers
and clusters of healthcare workers associated with a high index
of suspicion for SARS-CoV disease, as specified in the preceding
section.
B. Surveillance
in the Presence of Person-to-Person Transmission of SARS-CoV in the
World
Objective: Establish
surveillance to promptly identify and report all new U.S. cases of
SARS-CoV disease to facilitate outbreak management and control.
If person-to-person SARS-CoV transmission is documented in the United
States or abroad, the likelihood that a person with fever or lower respiratory
symptoms might be infected with SARS-CoV will increase but will remain
low unless the person has a history of recent exposure to a known case
of SARS-CoV disease or to a setting in which SARS-CoV transmission is
occurring. Surveillance efforts should be modified to incorporate available
risk factor information, particularly regarding geographic transmission
patterns. The scope of surveillance activities in specific communities
may differ substantially depending on the extent of disease in both the
community and local healthcare facilities or institutions. Ongoing analysis
of surveillance data and other information will be critical to inform
decisions about the need to implement or discontinue various elements
of enhanced surveillance.
Surveillance activities should also be enhanced or accelerated as needed
by a particular community or institution. Basic surveillance activities should
be initiated in areas with no or little SARS-CoV transmission and continued
in areas with increased transmission. Enhanced surveillance activities should
be considered if a community or facility experiences a significant increase
in number of cases, if epidemiologic links between cases cannot be readily
established, or if changing transmission patterns are identified. Enhanced
surveillance activities should focus both on increasing the sensitivity
of case detection through use of less specific clinical criteria when
screening cases (see note below) and on evaluation of suspicious illnesses
regardless of identification of an epidemiologic link.
NOTE: For
persons with a high risk of exposure to SARS-CoV (e.g., persons previously
identified through contact tracing or self-identified as close contacts
of a laboratory-confirmed case of SARS-CoV disease; persons who are
epidemiologically linked to a laboratory-confirmed case of SARS-CoV
disease), respiratory symptoms used to screen patients should be expanded
to include upper respiratory symptoms such as sore throat and rhinorrhea,
in addition to any other early non-respiratory symptoms of SARS-CoV
disease such as chills, rigors, myalgia, headache, or diarrhea. The
more common early symptoms include chills, rigors, myalgia, and headache;
in some patients, myalgia and headache may precede the onset of fever
by 12-24 hours. However, diarrhea, sore throat, and rhinorrhea may
also be early symptoms of SARS-CoV disease.
Activities:
Healthcare providers
Community-based surveillance
Basic Activities
Enhanced Activities
- If
epidemiologic links between some local SARS cases
cannot be readily established (i.e., the source of infection
is unclear) , consider SARS-CoV disease in the differential
diagnosis and management of all patients with fever or lower
respiratory symptoms, regardless of whether the patient has
SARS risk factors (see Supplement C and Supplement I for guidance
on triage and infection control).
Hospital-based
surveillance
This
section includes recommendations for SARS surveillance in healthcare
facilities. For detailed recommendations on screening and triage,
access controls, and infection control measures in healthcare
settings, see Supplement C and Supplement I.
Healthcare
facility with no cases of SARS
Basic Activities
- Continue
to implement case detection and reporting efforts as detailed
above (absence of SARS-CoV transmission in the world) to identify
potential SARS patients for whom an epidemiologic link is unknown.
- Screen
all patients presenting to emergency rooms or hospital clinics
with a fever or respiratory symptoms for SARS risk factors.
- Infection
control personnel, occupational health officials, and providers
should be alert for clusters of pneumonia requiring hospitalization
among healthcare workers. Any clusters with illness with onset within
the same 10-day period should be reported to local or state health
officials.
- Report any potential SARS cases to the state or local health department
according to their instructions.
Enhanced Activities
Healthcare facility with a few SARS cases, but no evidence of nosocomial
transmission
Basic Activities
- Continue
all recommended surveillance plans outlined in the previous
section. Implement daily monitoring of all healthcare workers
caring for SARS patients. If a healthcare worker caring for
SARS patients develops fever or lower respiratory symptoms
or two or more early symptoms of SARS-CoV disease (chills,
rigors, myalgia, headache, diarrhea, sore throat, rhinorrhea)
, notify the local health department, begin SARS isolation precautions,
and initiate a clinical evaluation as outlined in Clinical
Guidance on the Identification and Evaluation of Possible SARS-CoV
Disease among Persons Presenting with Community-Acquired Illness.
The more common early symptoms of SARS-CoV disease include chills,
rigors, myalgia, and headache; in some patients, myalgia and
headache may precede the onset of fever by 12-24 hours. However,
diarrhea, sore throat, and rhinorrhea may also be early symptoms
of SARS-CoV disease.
Enhanced Activities
- Screen
all patients, visitors, and employees upon entry to the facility
for fever or lower respiratory symptoms. Screen symptomatic persons
for SARS risk factors. Patients with risk factors should be isolated
and evaluated for both alternative respiratory illnesses and SARS-CoV
disease.
Healthcare
facility with a larger number of SARS cases OR nosocomial transmission
with all cases linked to a clearly identified source
Activities
- Continue
all recommended surveillance plans outlined in the previous section.
- Monitor all healthcare
workers daily for fever or lower respiratory symptoms. If a healthcare
worker has fever or lower respiratory symptoms, begin SARS isolation
precautions (Supplement I), obtain a chest x-ray, and initiate a
preliminary
clinical evaluation. Continue to screen all healthcare workers
caring for SARS patients using the expanded clinical criteria. In
addition to fever or lower respiratory symptoms, screen for the presence
of any of the following: chills, rigors, myalgia, headache, diarrhea,
sore throat, rhinorrhea.
- Begin
inpatient surveillance. Monitor patients daily for new or worsening
respiratory symptoms. If found, investigate the patient for exposure
to known or suspected SARS patients. If there is evidence of exposure,
isolate the patient and test for alternative respiratory illnesses
and SARS-CoV
disease.
Healthcare
facility with cases attributed to nosocomial transmission with no
clearly identified source
Activities
Activities:
State and local health departments
- Continue
activities outlined above, as appropriate.
- Identify,
evaluate, and monitor exposed contacts of SARS cases to identify previously
unrecognized or secondary cases, as outlined below.
- Disseminate
modified surveillance and patient screening guidelines to providers
through the state/local Health Alert Network.
- Facilitate
reporting from hospitals. If necessary, consider placming surveillance
staff in hospitals with multiple SARS admissions.
- Review
reports daily of persons reported from hospitals/providers to: 1) evaluate
the level of risk for SARS, 2) ensure adequate testing to rule out
SARS-CoV, 3) identify new clusters that might require special attention,
4) identify contacts and ensure that they are evaluated and monitored
(as outlined below), and 5) monitor trends.
- Once
person-to-person SARS-CoV transmission is documented anywhere in the
world, report to CDC any person who meets the case definition for a
probable case of SARS-CoV disease or a confirmed case of SARS-CoV disease,
as defined by CSTE (see Appendix B1).
- Immediately
report to CDC any positive SARS-CoV test results.
- Following
discussions between CDC and CSTE, CDC may also require reporting
of other potential SARS-CoV cases (e.g., SARS reports under investigation
[SARS RUIs]) as needed to meet national surveillance objectives.
Updated national reporting requirements will be circulated to state
and local health departments and posted on CDC's
SARS website as indicated.
Activities:
CDC
- Continue
activities outlined above, as appropriate.
- Ensure
that all states have systems to identify and monitor potential SARS
cases and contacts.
- Ensure
that states and hospitals have adequate guidance to implement effective
surveillance and containment measures.
- As SARS
activity evolves, work with CSTE to determine what surveillance information
and related reporting mechanisms are needed to meet national surveillance
objectives.
- Monitor
the level of activity of SARS-CoV disease nationwide to:
- Monitor
the effectiveness of U.S. efforts to diagnose and contain SARS-CoV
- Provide
timely feedback to states in the form of data and other information
- Mobilize
additional resources, and arrange surge capacity as needed
- Report
activity to WHO to assist with global surveillance and control
- Oversee
surveillance at ports of entry to aid in the identification of possible
imported SARS-related illnesses, as outlined in Supplement
E.
- Facilitate
coordinated surveillance and related activities in settings that may
not be under state/local jurisdiction (e.g., military bases).
- Provide
guidance regarding possible laboratory-acquired SARS-CoV infections,
as outlined in Supplement F.
1 Close
contact: A person who has cared for or lived with a person with SARS-CoV
disease or had a high likelihood of direct contact with respiratory
secretions and/or body fluids of a person with SARS-CoV disease. Examples
of close contact include kissing or hugging, sharing eating or drinking
utensils, talking within 3 feet, and direct touching. Close contact
does not include activities such as walking by a person or briefly
sitting across a waiting room or office.
2 Persons
who work in laboratories that contain live SARS-CoV should report any
febrile and/or respiratory illnesses to the supervisor. They should
be evaluated for possible exposures, and their clinical features and
course of illness should be closely monitored. If laboratory workers
with fever and/or respiratory illness are found to have an exposure
to SARS-CoV, they should be managed according to the recommendations
in Supplement F, Appendix F6.
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