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• W2896557949 abstract "Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS)http://www.cdc.gov/ncidod/sars/sarsprepplan.htm The draft guidelines are undergoing review by partner organizations and other federal agencies with plans for updating and response to public comment to be submitted to: [email protected]. The following is a brief summary divided in two sections dealing with background information and the recommendations.TABLE 9: Experience with the 2003 EpidemicLessons from the 2003 epidemic: The major risk for transmission is by droplet exposure and close personal contact; small particle aerosol is a lesser, but established risk. Strict adherence to contact and droplet precautions including eye protection appears to prevent most SARS-CoV transmission. Airborne precautions provide additional protection. The greatest risk for rapid spread is undetected cases. The social and psychological impact of SARS may be substantial during and after the outbreak. Laboratory tests do not reliably detect SARS-CoV early in the course. The clinical features of SARS are nonspecific in the early stages and the diagnosis is best guided by history of exposure. Transmission is not national or regional but very local. The median incubation period is 4-6 days with a range of 2-10 days. The case fatality rate is 10% but increases to over 50% in persons over 60 years of age. Children are relatively spared. Recurrence: It is not known if there will be recurrence, but the most likely sources if there is recurrence are: (1) an animal reservoir; (2) an undetected human source; or (3) a laboratory source. Based on this conclusion, the greatest risk for future cases are areas with prior outbreaks, areas with animal sources and laboratories that have worked with this virus. Following an outbreak, the subsequent sources are primarily the sites of cases and cases. Surveillance: The following factors are emphasized: Nosocomial spread accounted for 18-58% of cases in various locations in the 2003 epidemic. Health care workers accounted for about 50% of cases in Toronto so that surveillance of health care workers becomes an important part of epidemiologic investigation. Spread within households was also common. Thus, the major epidemiologic clues are typical symptoms combined with exposure to a SARS case, typical illness in health care workers, and persons from areas of prior outbreaks or animal sources and unexplained clusters of pneumonia. Typical clinical symptoms are simply fever with findings of a respiratory tract infection. The laboratory is not very helpful in the early stage of infection because the PCR is neither sensitive or specific. Based on these observations, in the absence of SARS cases, the following surveillance methods are recommended: Screen all hospitalized patients with community-acquired pneumonia for three risks:< Onset within 10 days of travel to or contact with persons who traveled to an area with prior SARS cases, Health care workers, and Person with close contact with another with x-ray confirmed pneumonia. Testing for SARS CoV should be done judiciously in the absence of SARS in the world. The positive predictive value of a positive early laboratory test is very low, a point worth emphasizing. Unexplained pneumonia in clusters, especially in two or more health care workers at the same facility, is an important potential clue. Suspect cases should be reported to the health department. Based on these observations, the draft guidelines make the following recommendations for hospitals, emergency departments, and outpatient clinics as divided into four categories: no SARS in the world, SARS in the world but not in the local area, SARS in the facility but all imported, and SARS in the facility with nosocomial spread. Recommendations for Hospitals and Emergency Departments: No SARS Triage: Adult patients-surgical mask (for tissue or cough) Triage staff-hand hygiene ± surgical mask in respiratory season SARS Evaluation Center-for febrile patients (?) Designated personnel: Trained and fit-tested for N95 masks plus; full SARS protection Surveillance: Report all HCW hospitalized with unexplained pneumonia SARS in world, no local Triage: Signs indicating epidemiologic risk-SARS evaluation center Patients: Screen for fever and epidemiologic risk-mask and airborne precautions (single, negative-pressure room) or cohort Triage staff-hand hygiene and surgical mask in respiratory season Designated personnel: Trained, fit-tested for SARS protection (goggles, gloves, N95 mask) Surveillance: Reporting per local health department Health care worker requirements, notify if: (1) care for SARS in other hospital; (2) work in another facility with SARS; or (3) close contact with SARS SARS in facility-all imported Triage: As above plus: (1) no unnecessary visitors; visitors get IC training; (2) SARS patient flow routes; (3) clean rooms Patient placement: Airborne isolation precautions if available or cohorting Designated personnel: Trained, fit-tested plus designated emergency resuscitation team Surveillance: (1) Daily monitoring of HCW with SARS patients; (2) furlough workers with unprotected exposures and daily symptom checks SARS in facility with nosocomial spread Triage: As above and close facility to admissions and transfers Patient placement: As above and consider cohorting patients and staff Designated personnel: Protective guidance for all patient care, surgical masks when not doing patient care Surveillance: as above HCW restrictions: as above Outpatient Facilities No SARS in world Screening: Patients with RTI-hand hygiene and surgical mask (or tissue). If delays-segregate HCW: For patients with RTI-surgical mask and hand hygiene Triage staff: Hand hygiene ± surgical mask SARS in world, not in facility Screening: Screen persons with epidemiologic risk (travel to epidemic area or case contact). If fever and epidemiologic risk-patient to private room. HCW: SARS protective guidance (gloves, N95 mask, goggles) for evaluation of patient at risk SARS in world and local transmission Screening: Screen all patients and visitors for RTI and fever when appointments made and at clinic. Refer to facility with isolation capacity and warn facility. HCW: As above. Comment: An important component of these recommendations is the adoption of respiratory tract infection etiquette in which all patients with respiratory tract infections have droplet and contact precautions. Although proposed in the context of possible SARS, this strategy should be effective in reducing transmission of common respiratory tract pathogens such as influenza, RSV, parainfluenza adenovirus, Mycoplasma pneumoniae, etc. Many in the field feel that these recommendations were sage advice long before SARS. One of the difficult issues in the SARS experience has been hospital closures. This would be a financial disaster for most hospitals in the US; in fact, it is estimated that most would face bankruptcy with a closure of just 2 weeks in duration due to the thin margin. It is noted that the hospital closures that have taken place have occurred exclusively in hospitals that are publicly supported and most were not actual closures, but restrictions in admissions and transfers. The CDC draft recommendations do not mention closures, but recommend that facilities with nosocomial spread be closed to admissions and transfers. This is the equivalent of red alert for most hospitals. Another issue concerns the importance of nosocomial dissemination of SARS with high rates of infections in health care workers who actually accounted for 50% of the cases in Toronto. For practical purposes, the implications are: (1) there may be a heavy toll on the work force, particularly those specialties that are in most demand (infection control, pulmonary specialists, and infectious disease specialists); (2) there has been concern that some health care workers would be reluctant to provide care due to personal risks, but this was clearly not the experience with SARS; for example, a request from Toronto for infectious disease specialists through the IDSA resulted in 150 volunteers within one hour of the announcement; (3) monitoring the health status of the care providers such as daily temps in nurses and attendance tracking. Nurse absenteeism is a recommended strategy when there is concern for SARS, and (4) the psychological impact of caring for critically ill co-workers may have a devastating impact that needs to be appreciated and dealt with. It is emphasized that the greatest risk is the unsuspected case and that pre-event planning is critical. One of the important lessons from Toronto is that management of the first wave was disorganized and inefficient, but the management of the second wave was well coordinated and highly effective." @default.
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• W2896557949 title "Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS)" @default.
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