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Guidance on Persons Suspected of Having
Severe Acute Respiratory Syndrome (SARS)
MGH Internal Summary
Updated 5/20/03
Stephen B. Calderwood
David C. Hooper
 There has been an outbreak of a severe febrile respiratory illness (SARS) that began in the Guangdong province of China, and now involves several areas in the Far East, as well as several other areas around the world, particularly Toronto, Canada.
Update of cases in the United States and Massachusetts
◎In the United States, as of May 14th, there have been 345 patients who meet the CDC clinicalcase definition of SARS; 281 (81%) of these patients were suspect cases and 64 (19%) were probable cases. Probable cases cases have evidence of pneumonia in addition to the other features of suspect SARS cases (full case definitions can be found at the link to the Infectious Diseases Division website below). Of the 64 probable SARS patients, 44 (69%) were hospitalized, and three (5%) required mechanical ventilation; there have been no reported deaths from SARS in the U.S. Ninety-seven percent of the U.S. SARS cases were attributed to exposures from international travel to areas with documented or suspected community transmission of SARS. There has been only one new probable SARS case reported in the U.S. in the first 2 weeks of May.

Ninety-three SARS patients, 73 suspect and 20 probable, have completed diagnostic testing for the SARS coronavirus. Based on assays for the development of specific antibody at least 3 weeks after illness, 6 of 20 (30%) probable cases were positive, and none of the suspect cases was positive.

◎In Massachusetts, as of May 7th, there have been 19 suspect and 2 probable cases, 5 of whom have been hospitalized. The last probable case was on April 20th. The results of SARS antibody testing on Massachusetts cases is still pending.
CDC Case Definition of SARS (updated April 29, 2003):
Suspected Case of SARS:
Respiratory illness of unknown etiology with onset since February 1, 2003, and the following criteria:
◎Measured temperature greater than 100.4° F (greater than 38° C) AND
◎One or more clinical findings of respiratory illness (e.g. cough, shortness of breath, difficulty breathing or hypoxia) AND
◎Travel (including transit in an airport) within 10 days of onset of symptoms to an area with currently or recently documented or suspected community transmission of SARS (see list below; excludes areas with secondary cases limited to healthcare workers or direct household contacts) OR Close contact* within 10 days of onset of symptoms with a person known or suspected to have SARS infection
Probable Case of SARS:
A suspect case with one of the following:
◎Radiographic evidence of pneumonia or respiratory distress syndrome
◎Autopsy findings consistent with pneumonia or respiratory distress syndrome without identifiable cause
Additional Notable Clinical Features (not part of the case definition):
 In a recent report of a series of cases of SARS from Toronto published in the May 14th issue of JAMA (accessible on the web at http://jama.ama-assn.org/), cases with comorbid disease, including diabetes, were noted to have significantly higher risk of death and a trend toward higher mortality was noted in patients over 60 years of age. The presence of lymphopenia (85% of patients), elevated levels of lactate dehydrogenase (87%), and hypocalcemia (60%) were common in this cohort of patients and might be useful for identifying SARS patients who meet the clinical case definition but for whom information on travel or other exposure to SARS patients is not available.
Areas with current documented or suspected community transmission of SARS:
 Peoples' Republic of China (mainland China and Hong Kong Special Administrative Region) and Taiwan. Singapore and Toronto, Canada no longer appear to have community transmission of SARS. Hanoi, Vietnam appears now to be free of SARS.
* Close contact is defined as having cared for or lived with a person known to have SARS, or having a high likelihood of direct contact with respiratory secretions and/or body fluids of a patient known to have SARS.
Laboratory criteria for SARS:
◎ Confirmed
- Detection of antibody to SARS coronavirus in specimens obtained during acute illness or >21 days after illness onset, or
- Detection of SARS coronavirus RNA by RT-PCR, confirmed by a second PCR assay using a second aliquot of the specimen and a different set of PCR primers, or
- Isolation of SARS coronavirus from patient samples
◎ Negative
- Absence of antibody to SARS coronavirus in convalescent serum obtained >21 days after symptom onset
◎ Undetermined
- Laboratory testing either not performed or incomplete
SARS is now a reportable disease in the state of Massachusetts. Cases meeting the CDC case definition must be reported as follows:
Inpatients: Infection Control Unit 617-726-2036
Outpatients: Massachusetts Department of Public Health 617-983-6800 (available 24/7)
Infection control procedures for managing patients meeting the CDC case definition of suspect OR probable SARS:
◎Contact precautions: Gowns and gloves for contact with patient or patient’s environment
◎Airborne precautions: Negative pressure room, wear N-95 respirator before entering patient’s room (respirators should be discarded after each use). Respirators should be properly fit-tested to provide maximum effectiveness in preventing transmission.
◎Eye protection (goggles or face shield) for all patient contact
◎Standard precautions: Hand hygiene (Cal Stat or soap and water) after removing protective equipment
◎When leaving the room of a patient with SARS, healthcare workers should remove gloves first, followed by the N-95 respirator and eye protection (goggles or face shield) and then the gown. Hand hygiene (with Cal Stat alone or soap and water followed by Cal Stat after drying hands) should be performed immediately after removal of the gown.
◎Contact Infection Control about restricted visitor access.
Outpatient Setting:
◎If a suspected SARS case, evaluate patient in separate area, if possible
◎Place a surgical mask on the patient, if possible
◎Health care worker should, if possible, wear an N-95 respirator (wear surgical mask if N-95 respirator is not available), as well as gown, gloves and eye protection for all patient contact. Discard respirator after use.
◎Hand hygiene with Cal Stat or soap and water before and immediately after patient contact
◎If patient is transported to the ED for further evaluation (call in advance), patient should wear a surgical mask and persons transporting patient should wear N-95 respirator
Home or Residential Setting (patients should be advised to remain in their home and utilize precautions until 10 days after resolution of fever, as long as respiratory symptoms have also resolved):
◎Place a surgical mask on SARS patient during periods of close contact with others in the home
◎If patient is unable to wear a surgical mask, household members should be advised to wear surgical mask when in close contact with the patient
◎Hand hygiene for household members after contact with the patient
Precautions for Testing Done in Patients Who Meet the Case Definition for Suspect or Probable SARS:
Imaging Studies:

◎Place surgical mask on patient; notify the testing area so that technicians who are in direct contact with the patient can wear a N-95 respirator, if possible
◎Hand hygiene before and after all patient contact
Blood Tests:
◎Label specimens “R/O SARS” – see below
◎When obtaining blood, use precautions as above, with hand hygiene before and after blood draw
Diagnostic Testing for SARS:
◎The CDC and others have identified a new coronavirus in patients meeting the case definition of SARS, and this virus has now been shown to produce a similar respiratory illness in primates, suggesting that it has a causative role in the disease. Of note, evidence of this coronavirus has been found in only 6 of 20 probable SARS cases in the US for which testing is complete, and none of 73 in the suspect SARS category. At the present time, a negative test for this coronavirus at the CDC during acute illness in a patient who still meets the clinical case definition of SARS, is not a reason to change the overall medical precautions in such a patient.
◎Specimens from patients should only be sent for SARS testing if the patient meets the CDC case definition as defined above. If they do not, specimens should not be sent for such testing or labelled “R/O SARS”. If the patient meets the case definition, the following MGH guidelines are provided for specimen collection. Please note that prior approval by an epidemiologist at the Massachusetts Department of Public Health is required for the specimens to be sent to the CDC for SARS testing, as outlined below.
MGH Guidelines for Specimen Collection and Department of Public Health approval for SARS Testing:
Specimen Collection:

◎Nasal wash, nasal aspirate, or nasal swabs (use dacron swabs) in saline for rapid viral panel at the MGH (to evaluate for other respiratory viruses)
◎Nasopharyngeal or oropharyngeal swabs (dacron swabs are required by CDC ) in viral transport media for shipment to CDC
◎If available, sputum, BAL, or other lower respiratory secretions should be sent in a sterile container for testing at both MGH and shipment to the CDC
◎Red top tube of blood
◎Purple top tube of blood
Approval by MDPH Epidemiologist:
 As soon as possible
, call the Epidemiologist-on-call at the Massachusetts Department of Public Health 617-983-6800 (available 24/7) for case approval. If approved, a Case ID # will be assigned and this number MUST go on the submission form that the microbiology laboratory sends to the State Laboratory.
Specimen Transport:
the case is accepted for testing by the MDPH, then label ALL laboratory requisitions “R/O SARS”. This includes specimens for Chemistry and Hematology etc. DO NOT use the pneumatic tube system.
CDC and State Department Travel Advisories and Alerts:
 Travel advisories
remain in place for China, Hong-Kong, and Taiwan because of continuing community transmission of SARS in those areas. Travelers are advised to postpone any non-essential travel to those areas. Incoming travelers from those areas continue to be provided instructions on entry into the United States to monitor their health for 10 days after return and to seek medical attention and avoid work or public areas if they develop fever and respiratory symptoms. Quarantine of asymptomatic incoming travelers is not currently recommended, and there is no evidence as yet that SARS is transmitted by persons without symptoms.
Travel alerts are in place for Toronto and Singapore for which the CDC does not recommend postponing travel but advises caution and avoidance of areas most likely to have SARS patients, such a healthcare settings. The travel alert for Hanoi previously in place has been removed.

 The government of Thailand has instituted a program of screening all passengers arriving from SARS-affected areas and disembarking, regardless of whether they originated in, or transited through, these areas (China, Hong Kong, Vietnam, Singapore, Taiwan). Because of this practice, the Department of State is alerting travelers that persons with respiratory illnesses arriving in Thailand from these areas may be isolated and quarantined there for up to 14 days.
For Assistance:
Case identification, diagnosis, and management:
 Infectious Disease Division
 617-726-3812 (or page ID fellow on call)

Infection control/transmission questions:
 Infection Control Unit
 617-726-2036 (or page ID fellow on call)

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