Severe Acute Respiratory Syndrome (SARS)

Severe Acute Respiratory Syndrome (SARS) is thought to be to be a viral illness, spread person to person through close contact with respiratory secretions. The severity of illness is highly variable, from mild illness to death. The following information is provided to assist firefighters in identifying people who may transmit SARS and to advise all those with potential SARS exposure to use infection control precautions to protect their own health and that of the public.

What is the Cause for Concern About SARS?

On March 16,2003 the World Health Organization issued a Global Alert regarding the SARS epidemic. The Alert was issued because this disease was not previously recognized, it caused great risk to exposed health care workers, and it began to spread internationally. As of April 2, there were 2,223 cases, including 48 deaths reported. This represents a case fatality rate of 3.5%.

In Canada, 208 paramedics have been quarantined, as well as 40 social workers and four library workers. Three Canadian paramedics and three hospital workers have SARS. The disease has also been transmitted to airline passengers in close proximity to persons with active SARS. As of April 1, thirteen countries have been affected. Of these, four countries imported cases with no documented local transmission. Fortunately, the Global Alert appears to have prevented spread in countries where the disease was imported. There is no indication that SARS is linked to bioterrorism.

What Is The Cause of SARS?

Scientists at CDC and other laboratories have detected a previously unrecognized corona virus in patients with SARS. While the new coronavirus is still the leading hypothesis for the cause of SARS, other viruses are still under investigation as potential causes.  Coronaviruses are a group of viruses that have a halo or crown-like (corona) appearance when viewed under a microscope. These viruses are a common cause of mild to moderate upper-respiratory illness in humans and are associated with respiratory, gastrointestinal, liver and neurologic disease in animals. Coronaviruses can survive in the environment for as long as three hours.

If coronaviruses usually cause mild illness in humans, how could this new corona virus be responsible for a potentially life-threatening disease such as SARS?

There is not enough information about the new virus to determine the full range of illness that it might cause. Coronaviruses have occasionally been linked to pneumonia in humans, especially people with weakened immune systems. The viruses can also cause severe disease in animals, including cats, dogs, pigs, mice, and birds.

When Should I Suspect a Case of SARS?

There are two situations in which you should suspect SARS

1)  You should suspect that a person may have SARS if the following conditions apply:

OR

2)  You should suspect SARS in a person who was in close contact with a person having SARS, or a person with a respiratory illness who traveled to a SARS area. Close contact is defined as having cared for, having lived with, or having direct contact with respiratory secretions and/or body fluids of a patient suspected of having SARS. The close contact should have occurred within 10 days of symptom onset.

Ø     Note: do not rely on a history of foreign travel/contact with foreign travelers in order to don protective gear

How Does the Illness Progress?

The illness usually begins with fever (> 100.5º F), sometimes with chills or other, nonspecific symptoms (headache, muscle aches). Typically, rash and neurologic or gastrointestinal findings are absent; however, some patients have reported diarrhea during the fever phase.

After 3-10 days, a lower respiratory phase begins, with a dry cough or shortness of breath, which may be associated with diminished blood oxygen level. In 10-20% of cases, the respiratory illness is severe enough to require intubation and mechanical assistance with breathing. The case-fatality rate among persons meeting the above definition of SARS is 3-4%. Of the persons who died, many had a pre-existing condition, such as diabetes, that weakened their immune systems and made them susceptible to complications of an infection.

Some close contacts of SARS patients have reported a mild illness with fever, without respiratory signs, suggesting the illness does not always progress to the respiratory phase.

Ninety per cent of people who have contracted SARS have improved and were in a recovery phase at day seven after disease.

How Can I Protect Myself?

The best protection against SARS is strict adherence to infection control procedures.

Follow universal precautions, including respiratory precautions when SARS is suspected. Additionally, fire department should have an Infection Control program that meets the minimum requirements of NFPA 1581, Standard on Fire Department Infection Control Program.

In situations where the patient has a high fever and any respiratory signs:

When using an alcohol-based handwashes, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product.

Personnel should avoid wearing artificial nails and keep natural nails less than one quarter of an inch long, particularly if they come in contact with patients at high risk of acquiring infections.

How Do I Decontaminate Equipment?

What Advice is Given to Contacts of a Suspected SARS Patient?

How Contagious is SARS?

Although the infectivity and definite cause of SARS are currently unknown, transmission to healthcare workers appears to have occurred after close contact with SARS patients before recommended infection control precautions were implemented (hand hygiene, gloves, respirator, eye protection, gown). SARS is not highly contagious when protective measures are used. SARS is not thought to be spread through building ventilation systems.

SARS appears to be less infectious than influenza. The incubation period is usually from 2-7 days, with 3-5 days being most common. Contact with aerosolized respiratory secretions from an infected person appears to be important. It is unknown whether other body fluids are infectious, therefore, all body secretions from suspected SARS patients should be handled only while wearing appropriate protection.

Is a Respirator Effective Against SARS Transmission?

When properly fitted, maintained and used, a P100 respirator (or a full or half face air purifying respirator with a HEPA filter) provides excellent protection from inhalation of infectious airborne droplets. However, there are NO safe exposure levels (i.e. the amount you can inhale without adverse health effects) for biological aerosols. Respirators can reduce inhalation exposures but cannot eliminate the risk of contracting infection, illness, or disease. Additionally, the type of respirator facepiece and filter class required does vary depending activities and risk of exposure. Many have suggested that N95 respirators be used for protection from this disease for public and hospital use. The IAFF does not believe that this type of respirator will afford fire fighter and emergency medical personnel proper protection. Accordingly, the IAFF recommends for emergency response, as a minimum, a P100 respirator be used. One of the easiest ways of transmitting a viral infection from one person to another is through a hand shake that transfers virus from the hand of one person who may have rubbed his nose to another person's hand. The second individual then touches his/her nose or mouth, then develops an infection. A respirator is not a guarantee of protection against any disease. However, if a high-filtration respirator is worn with eye protection and gloves, a high degree of protection is conferred.

Is There a Test for SARS?

Three diagnostic tests are now available, however, all have limitations as tools for early SARS detection. The CDC is working to refine and share this testing capability as soon as possible with laboratories across the United States and internationally.

What is the Treatment for SARS?

While some medicines have been tried, no drug can, at this time, be recommended for definitive treatment of SARS. Antibiotics do not appear to be effective. As a result of good, supportive hospital care, more than 60 persons diagnosed with SARS have been discharged from Asian hospitals.

Should I Be Worried?

SARS can be severe and, due to global travel, has spread to several countries in a relatively short period of time. However, SARS is not highly contagious when protective measures are used. The percentage of cases, although significant, is relatively low. Remember that SARS is transmitted only from infected persons who have signs of an active respiratory illness.

Since the WHO Global Alert was issued on March 15, isolated cases have been identified and no secondary outbreaks have occurred. Health authorities around the world are watching closely for, and quickly reporting, suspected cases. Reports of many illnesses coming in from around the world will turn out to represent the normal activity of diseases like influenza, whose early symptoms are similar to SARS. Evidence on the spread of SARS needs to be evaluated daily, therefore, future recommendations may change.

Medical Transport Guidance for Severe Acute Respiratory Syndrome (SARS) Patients

Travel and Quarantine

What are CDC's quarantine officials doing to prevent and control the spread of SARS?

CDC's quarantine inspectors or their designees are distributing health alert cards (http://www.cdc.gov/ncidod/sars/travel_alert.htm) to air passengers returning in airplanes either directly or indirectly to the United States from China, Singapore, and Vietnam. The notices ask travelers to monitor their health for 10 days and to see a doctor if they get a fever with a cough or have difficulty breathing. CDC distributes approximately 15,000 health alert notices each day to air travelers returning from the affected regions at 23 ports of entry. Inspectors also are boarding airplanes if a traveler has been reported with symptoms matching the case definition of SARS.

The World Health Organization (WHO) has recommended procedures (http://www.who.int/csr/sars/travel/en/) for pre-departure screening of airline passengers from some countries for respiratory illnesses or other symptoms of SARS.

What is the risk to individuals who may have shared a plane or boat trip with a suspected SARS patient?

Cases of SARS continue to be reported primarily among persons who have had direct close contact with an infected person, such as those sharing a household with a SARS patient and health care workers who did not use infection control procedures while attending to a SARS patient. SARS has also occurred among air travelers, primarily travelers to and from Hong Kong, Hanoi, Singapore, and mainland China.

CDC is requesting locating information from travelers who are on flights with people suspected of having SARS. CDC, with the help of state and local health authorities, is attempting to follow-up with these travelers for 14 days to make sure no one develops symptoms consistent with SARS.

Who actually notifies quarantine officials of potential SARS cases? Is it the crew of the airplane or ship? The passengers?

Under foreign quarantine regulations, the master of a ship or captain of an airplane coming into the United States from a foreign port is required by law to report certain illnesses among passengers. The illness must be reported to the nearest quarantine official. If possible, the crew of the airplane or ship will try to relocate the ill passenger or crewmember away from others. If the passenger is only passing through a port of entry on his/her way to another destination, port health authorities may refer the passenger to a local health authority for assessment and care.

What does a quarantine official do if a passenger identified as meeting the case definition for suspected SARS refuses to be isolated?

On April 4, 2003,President Bush signed an executive order adding SARS to the list of quarantinable communicable diseases under the Public Health Service Act. Many levels of government (Federal, State, and local) have basic authority to compel isolation of sick persons to protect the public. In the event that it is necessary to compel isolation of a sick passenger, CDC will work with appropriate State and local officials to ensure that the passenger does not infect others.

Where Can I Learn More?

Updated information on SARS is available on the following Web sites:

World Health Organization                www.who.int/csr/sars/en/

Centers for Disease Control              www.cdc.gov

Health Canada                                  www.hc-sc.gc.ca