1. 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

2. SARS Presentation Overview The presentation has five sections: 1.Chronology and Clinical Features 2.Command and Control 3.Surveillance & Case and Contact Investigations 4.Infection Control & Roles of Healthcare System 5.Isolation and Quarantine

3. SARS & Preparedness for Biological Emergencies Surveillance

4. 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 Syndrome Case 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 Emergencies Washington 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 Emergencies Washington 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 Syndrome CDC Case Definition* Clinical criteria - compatible illness Epidemiological criteria - relevant exposure history Laboratory criteria - confirmation Exclusion criteria *12 December 2003

9. Severe Acute Respiratory Syndrome CDC 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 Criteria Possible 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 Syndrome CDC 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 Syndrome CDC 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 Syndrome CDC 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 ?