SARS Presentation Overview

1. Severe Acute Respiratory Syndrome (SARS) and Preparedness for Biological Emergencies27 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

2. SARS Presentation Overview The presentation has five sections: • Chronology and Clinical Features • Command and Control • Surveillance & Case and Contact Investigations • Infection Control & Roles of Healthcare System • Isolation and Quarantine

3. SARS & Preparedness for Biological EmergenciesSurveillance

4. SARS & Preparedness for Biological Emergencies Surveillance • Ensure prompt recognition and reporting of SARS, BT or other outbreak of public health significance • Healthcare providers/facilities must be aware of evolving SARS screening criteria and case definitions and guidelines • Need methods for rapidly communicating urgent information from public health authorities to health care providers and facilities • Need specialized databases

5. Severe Acute Respiratory SyndromeCase and Contact Investigations • Labor/time intensive investigations • Monitoring and management of cases and contacts • Case and contact monitoring teams • Prioritization of cases and contacts for investigation and management • Healthcare worker exposures • Tracking diagnostic laboratory test results • Provision of supplies and other needs for persons in isolation • Need standardized approach/training for “surge capacity” staff • Isolation and quarantine - legal, political, social considerations Special databases

6. SARS & Preparedness for Biological EmergenciesWashington Administrative Code (WAC) 246-101 Notifiable Conditions and the Health Care Provider • Who is required to report notifiable conditions? • Principal health care providers, and • Other physicians in attendance unless notification has already been made, and • Health care facilities • Laboratory reporting does not relieve the health care provider of his/her reporting obligation • Different timeline and content of notifications, not duplicate system

7. SARS & Preparedness for Biological EmergenciesWashington Administrative Code (WAC) 246-101 Notifiable Conditions and the Health Care Provider • WAC specifies what diseases are notifiable and within what time frame, and means and content of notifications • Report outbreaks and suspected outbreaks • Cooperate with public health authorities during investigations of cases and suspected cases of notifiable diseases • Provide adequate and understandable instruction in disease control measures to each patient who has been diagnosed with a communicable disease and to contacts who may have been exposed the disease

8. Severe Acute Respiratory SyndromeCDC Case Definition* • Clinical criteria - compatible illness • Epidemiological criteria - relevant exposure history • Laboratory criteria - confirmation • Exclusion criteria *12 December 2003

9. Severe Acute Respiratory SyndromeCDC Case Definition (DEC 2003): Clinical Criteria • Early illness: 2 or more of the following: • Fever; chills; rigors; myalgia; headache; diarrhea; sore throat; rhinorrhea • Moderate respiratory illness • Temperature >100.4°F (>38° C) AND • One or more clinical findings of lower respiratory illness (e.g. cough, shortness of breath, difficulty breathing,) • Severe respiratory illness • Meets clinical criteria for mild-moderate respiratory illness, and • Radiographic evidence of pneumonia or ARDS, OR • Autopsy findings consistent with ARDS or pneumonia in the absence of an identifiable cause

10. Severe Acute Respiratory Syndrome CDC Case Definition: Epidemiological CriteriaPossible exposure to SARS-CoV In the 10 days before onset of symptoms: • Travel to a foreign or domestic location with documented or suspected recent transmission of SARS-CoV (No areas with current documented or suspected community transmission of SARS). OR • Close contact with a person with mild-to-moderate or severe respiratory illness and a history of travel within 10 days of onset of symptoms to a foreign or domestic location with documented or suspected recent transmission of SARS-CoV.

11. Severe Acute Respiratory Syndrome CDC Case Definition: Epidemiological Criteria Likely exposure to SARS Co-V In the 10 days before onset of symptoms: • Close contact with a person with confirmed SARS-CoV disease OR • Close contact with a person with mild-to-moderate or severe respiratory illness for whom a chain of transmission can be linked to a confirmed case of SARS-CoV disease in the 10 days before onset of symptoms

12. Severe Acute Respiratory SyndromeCDC Case Definition: Laboratory Criteria Laboratory confirmed: • Detection of serum antibody to SARS-CoV by a test validated by CDC OR • Detection of SARS-CoV RNA by RT-PCR test validated by CDC with subsequent confirmation by CDC OR • Isolation in cell culture of SARS-CoV from a clinical specimen

13. Severe Acute Respiratory Syndrome CDC Case Definition: Exclusion Criteria • An alternative diagnosis can fully explain the illness • Antibody to SARS-CoV is undetectable in a serum specimen obtained >28 days after onset of illness • Case was reported on the basis of a contact with a person subsequently excluded as a case of SARS (provided other epidemiological or laboratory criteria are not present)

14. Severe Acute Respiratory SyndromeCDC Case Definition: Case Classification • Classified based on combination of clinical,epidemiological and laboratory data • SARS Reports Under Investigation - Reports in persons from areas where SARS is not known to be active • SARS RUI-1: Cases compatible with SARS in groups likely to be first affected by SARS-CoV if SARS-CoV is introduced from a person without clear epidemiologic links to known cases of SARS-CoV disease or places with known ongoing transmission of SARS-CoV

15. Severe Acute Respiratory Syndrome CDC Case Definition: Case Classification SARS Reports Under Investigation - Reports in persons from areas where SARS activity is occurring • SARS RUI-2: Cases meeting the clinical criteria for mild-to-moderate illness and the epidemiologic criteria for possible exposure (spring 2003 CDC definition for suspect cases • SARS RUI-3: Cases meeting the clinical criteria for severe illness and the epidemiologic criteria for possible exposure (spring 2003 CDC definition for probable cases) • SARS RUI-4: Cases meeting the clinical criteria for early or mild-to-moderate illness and the epidemiologic criteria for likely exposure to SARS-CoV

16. Severe Acute Respiratory SyndromeCDC Case Definition: Case Classification SARS-CoV disease • Probable case of SARS-CoV disease: meets the clinical criteria for severe respiratory illness and the epidemiologic criteria for likely exposure to SARS-CoV • Confirmed case of SARS-CoV disease: clinically compatible illness (i.e., early, mild-to-moderate, or severe) that is laboratory confirmed

17. Approach to Fever and/or Respiratory Symptoms in The Absence of SARS Activity Worldwide SARS Screening by Healthcare Providers: Key Points • Patients developing SARS may present with fever OR respiratory symptoms • To prevent exposure of healthcare workers and patients to SARS, need to identify potential cases at point of first contact with health care system using screening criteria • Presence of current epidemiological criteria (exposure history) is the only way to identify potential SARS cases among persons with a compatible clinical syndrome • Specific screening criteria and corresponding recommendations for management of possible SARS cases will vary according to the level of SARS worldwide and locally

18. Approach to Fever and/or Respiratory Symptoms in The Absence of SARS Activity Worldwide Questions/Discussion: Surveillance &Case and Contact Investigations ?