Severe Acute Respiratory Syndrome (SARS) and Preparedness for
Biological Emergencies 27 April 2004
Jeffrey S. Duchin, M.D. Chief, Communicable
Disease Control, Epidemiology and
Immunization Section, Public Health - Seattle &
King County Division of Allergy and Infectious Diseases,
University of Washington
Supplemental Slides
• The following slides contain supplemental information.
Fever or Respiratory Illness1 in Adults Who May Have Been Exposed to SARS
Begin SARS isolation precautions, initiate preliminary work-up; notify Health Department2
No Radiographic Evidence of Pneumonia
No Alternative Diagnosis
Continue SARS isolation and re-evaluate72 hours after initial evaluation
Persistent fever or unresolving respiratory symptoms
Perform SARS test; continue SARS isolation for additional 72 hr. At end of the 72 hrs, repeat clinical evaluation including CXR
No radiogrpahic evidence of pneumonia
Symptoms improve
or resolve
- CXR
Draft-Algorithm to Work Up and Isolate Symptomatic Persons who may have been Exposed to SARS
+ CXR
Alternative diagnosis confirmed3
Consider D/C SARS isolation precautions5
Consider D/CSARS isolation
precautions5 Use algorithm for CXR + cases
Draft- Algorithm to Work Up & Isolate Symptomatic Persons who may have been Exposed to SARS
Perform SARS testing
Laboratory evidence of SARS-CoV or
No alternative diagnosis
Alternative diagnosisconfirmed
Continue SARS isolation until 10 days following resolution offever given respiratory symptoms are absent or resolving
Consider D/CSARS isolation
precautionsUsing Alternative Diagnosis to Rule Out” SARS• Based on test with high positive predictive value• Clinical course consistent• No evidence of clustering• No strong epidemiologic lin
Fever or Respiratory Illness1 in Adults Who May Have Been Exposed to SARS
Begin SARS isolation precautions, initiate preliminary work-up; notify Health Department2
Radiographic Evidence of Pneumonia
Severe Acute Respiratory Syndrome Symptoms and Signs
Symptom Range (%)Rales/Rhonchi 38-90Hypoxia 60-83
Sign Range (%)Fever 95-100Cough 57-100Dyspnea 20-100Chills/Rigor 73-90Myalgias 20-83Headache 20-70Diarrhea 10-67Nausea/Vomiting 10-24 (Rhinorrhea) 5-25(Sore Throat) 5-25
Severe Acute Respiratory Syndrome Laboratory Findings
Range (%) Finding
17-34
70-95
30-50
40-60
20-30 (2-6X ULN)
70-94
30-40 (up to 3000 IU/L)
Leukopenia*
Lymphopenia
Thrombocytopenia*
Prolonged aPTT
Increased ALT
Increased LDH
Increased CPK
*Total WBC count normal or decreased; absolute lymphocyte count may be decreased early in course. At the peak of respiratory illness, approximately 50% of patients have leukopenia and thrombocytopenia or low-normal platelet counts.
Severe Acute Respiratory Syndrome Chest Radiograph and CT
• Up to 30% normal at presentation• Infiltrates subsequently develop in nearly all laboratory
confirmed cases– 66% by day 3; 97% by day 7; 100% by day 10
• A “substantial proportion” of cases show early focal interstitial infiltrates progressing to more generalized, patchy interstitial infiltrates
• Focal consolidation• HRCT: Ground-glass opacification with or without thickening
of the intra-lobular or interlobular interstitium +/- consolidation
Wong. Radiology 2003;228:401-6; Wang. Proceedings of International Science Symposium on SARS. Beijing, China, 2003; Xue. Chin Med J 2003;116:819-822; Zhao. J Med Microbiol 2003;52:715-20. Rainer. BMJ 2003;326:1354-8.
SARS & Other Public Health Emergencies Diagnostic Testing: Key Concepts
• Be familiar with the appropriate diagnostic/laboratory tests
• Interpretation of results of new tests and implications for patient management
• Special procedures for obtaining and submitting specimens
• Biosafety considerations: precautions to protect laboratory workers
Severe Acute Respiratory SyndromeCDC Case Definition: Close Contact
• Close contact is defined as having cared for or lived with a person known to have SARS, or having a high likelihood of direct contact with respiratory secretions and/or body fluids of a patient known to have SARS during encounters with the patient or through contact with materials contaminated by the patient.
• Examples of close contact include kissing or embracing, sharing eating or drinking utensils, close conversation (<3 feet), physical examination, and any other direct physical contact between persons.
• Close contact does not include such activities such as walking by a person or sitting across a waiting room or office for a brief period of time.
Severe Acute Respiratory Syndrome What to Do Now: Absence of SARS Activity Worldwide
but in the presence of avian influenza H5N1• Identify all patients hospitalized with pneumonia and one of the
following risk factors:
• 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
• Travel within 10 days of symptom onset to a country with H5N1 avian influenza in poultry or humans
• 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. • Report to public health all cases answering yes to one of the above, and
clusters of unexplained pneumonia
Severe Acute Respiratory Syndrome What to Do Now: Absence of SARS Activity Worldwide
• For patients with pneumonia or ARDS who have recently traveled to Guangdong Province, China, diagnostic testing for SARS-CoV should be performed immediately.
• For others answering yes to one of the screening questions:
– Droplet precautions (Consider SARS isolation precautions if patient thought to be at high-risk after consultation with Public Health)
– Evaluate for alternative diagnosis
– Look for evidence of clustering
– Reassess after 72 hours and consider SARS testing if no alternative diagnosis and evidence of clustering or other reason to consider patient at high risk for SARS
Severe Acute Respiratory Syndrome When to Have a High Suspicion for SARS In the Absence
of SARS Activity Worldwide
• Situations in which a high suspicion for SARS is appropriate • The patient is part of a cluster of two or more healthcare
workers who 1) are hospitalized for CXR-confirmed pneumonia or ARDS 2) had direct patient contact, 3) have worked in the same facility, and 4) had illness onset within same 10-day period, OR
• The patient has 1) no alternate diagnosis that could explain the illness, 2) recently returned from a previously SARS affected area, and 3) either had close contact with someone hospitalized for a respiratory infection or visited a hospital while in the previously affected area and within 10 days of their illness onset.
Evaluation & management of patients requiring hospitalization for radiographically confirmed pneumonia, in the absence of person-to-
person transmission of SARS-CoV in the world
