First Appeared Thursday, 10 April '03

UCSF Experts Offer Advice About SARS

As the Centers for Disease Control and Prevention (CDC) continues to investigate the cause of severe acute respiratory syndrome (SARS), UCSF experts emphasize that most people with respiratory symptoms do not have SARS and that use of appropriate infection control measures can prevent transmission of the disease.

In addition, they recommend a consultation with a health care provider if individuals match the SARS case definition. This includes:

1) Temperature greater than 100.4 ° F (> 38° C)

2) One or more symptoms of respiratory illness (cough, shortness of breath, difficulty breathing) AND

3) Travel within 10 days of symptom onset to an area with suspected community transmission of SARS

4) OR close contact within 10 days of onset of symptoms with either a person with respiratory illness who traveled to a SARS area or a person known to be a suspect SARS case.

Areas of documented or suspected community transmission of SARS include the Peoples’ Republic of China (mainland China and Hong Kong special administrative region); Hanoi, Vietnam; and Singapore. Close contact is defined as having cared for, lived with or had direct contact with respiratory secretions and/or body fluids of a patient known to be a suspected SARS case.

As of April 9, the World Health Organization (WHO) has reported 2,722 cases in 18 countries. The US is reporting 154 suspected cases under investigation. There have been 106 deaths internationally and no deaths in the US so far. Most of the US patients are doing well and recovering, according to Julie Gerberding, MD, director of the CDC.

While the cause of SARS is not yet known, scientists suspect it is a new and more dangerous form of coronavirus, a family of viruses that causes colds and diarrhea. Two weeks ago, using a technology that he and colleagues developed, Joe DeRisi, PhD, UCSF assistant professor of biochemistry and biophysics, led a team that provided the CDC with important supporting evidence that coronavirus may be the cause of SARS. DeRisi’s work is sponsored by an award from the Sandler Program for Asthma Research.

“The mechanism by which SARS is transmitted is unknown, but evidence suggests that the SARS infection is spread by close contact between people,” said John Conte, MD, director of hospital epidemiology and infection control at UCSF Medical Center. He explained that it is most likely spread when a sick person coughs droplets into the air, which are then breathed in by someone else or come into contact with the lining of the eyes (conjunctivae). It is also possible that SARS can be spread more broadly through the air or from touching objects that have been contaminated.

Along with the fever, SARS symptoms may also include headache, an overall feeling of discomfort, body aches, and/or mild respiratory symptoms. After two to seven days, SARS patients may develop a dry cough and have trouble breathing. After exposure, the incubation period for SARS is typically 2-7 days. However, isolated reports have suggested an incubation period as long as 10 days. The majority of patients identified with the disease have been adults 25-70 years old who were previously healthy. Few cases have been reported among children aged 15 years or less.

Because there is no simple test to diagnose SARS, health care providers at UCSF Medical Center are using targeted screening questions concerning fever, respiratory symptoms, and recent travel to evaluate patients. The CDC currently recommends that patients with SARS receive the same treatment that would be used for any patient with community-acquired atypical pneumonia of unknown cause. Reported therapeutic regimens have included antibiotics and antiviral agents such as oseltamivir or ribavirin. Steroids also have been administered in combination with ribavirin and other antimicrobials. However, there is insufficient information at this time to determine if they have had a beneficial effect, according to Gerberding. (See UCSF guidelines.)

Infection Control

SARS is clearly a threat to health care workers who come in close contact with these patients, according to Conte. He added that the reports to date show that the health care workers who have become infected had unprotected exposures. Therefore, careful adherence to infection control guidelines is the best protection. If a suspect SARS patient is admitted to UCSF Medical Center, infection control measures include: hand hygiene, eye protection, use of gown and gloves for contact with the patient or their environment and the implementation of airborne precautions. Airborne precautions include the use of a negative pressure isolation room with adequate ventilation and use of high filtration N-95 masks for people entering the patient room. N-95 masks effectively remove 95 percent of particulates and are reusable as long as they remain dry and intact. In addition, patients should be instructed to cover their mouths and noses with a tissue before sneezing or coughing, said Conte.

Guidelines for Exposure

The CDC recommends the following guidelines for healthcare workers to manage exposure to SARS:

1) Exclusion from duty is recommended for a healthcare worker if fever or respiratory symptoms develop during the 10 days following an unprotected exposure to a SARS patient. Exclusion from duty should be continued for 10 days after the resolution of fever and respiratory symptoms. During this period, infected workers should avoid contact with persons at work and in the community.

2) Exclusion from duty is NOT recommended for an exposed healthcare worker if the worker has neither fever or respiratory symptoms. But the worker should report immediately any unprotected exposure to SARS patients to infection control or employee health. (See phone numbers below).

3) Active surveillance for fever and respiratory symptoms (daily screening) should be conducted on healthcare workers with unprotected exposure, and the worker should be vigilant for onset of illness. Workers with unprotected exposure developing such symptoms should NOT report for duty, but should stay home and immediately report symptoms to infection control or employee health. (See phone numbers below).

4) Close contacts (family members) of SARS patients are at risk for infection. Close contacts with either fever or respiratory symptoms are not allowed to enter the medical center and visitors should be educated about this policy. Signage posted around the medical center informs visitors not to visit patients if they have respiratory symptoms.

Return to Work

Employees do not need to stay home if they have not developed fever or respiratory symptoms. However, those exposed to a SARS patient should report the unprotected exposure to infection control 476-5793. Employees who have symptoms or feel they might match the SARS case definition should contact:

Diane Vogelei, RN, MS, ANP, at Employee Health, 885-7580, if they are medical center employees.

Evie McDonald, RN, coordinator of the Communicable Disease Prevention Program, 514-3861, if they are campus employees.

Students

The same guidelines apply to students. Students who have symptoms and have traveled or have had close contact with someone who has traveled to the identified countries, or contact with a suspected SARS case, should see their physician and not attend classes until they get medical clearance. Students who have symptoms or feel they might match the SARS case definition should contact Student Health Services at 476-1281.

Travel Precautions

On April 2, WHO revised its advice to international travelers recommending that persons traveling to Hong Kong and the Guangdong Province of China consider postponing all but essential travel as a measure for preventing the further international spread of SARS. On April 4, 2003, President Bush issued an executive order allowing the Health and Human Services secretary to decide when forced quarantine of patients with SARS symptoms is necessary. More information on travel precautions can be found online.

Reporting Suspected Cases

Medical Center clinicians who identify patients that meet the case definition of SARS are to report them to Infection Control: 476-5793 and the SFDPH: 554-2830. Campus clinicians, including dental clinicians who suspect cases of SARS should report them to the Communicable Disease Program at 502-1207 and SFDPH: 554-2830. UCSF clinical guidelines for SARS are largely based on CDC guidelines, which appear on the CDC website.

Source: Maureen McInaney

Links:

UCSF Medical Center Guidelines

Centers for Disease Control and Prevention