WHO: Alert, verification and public health management = of SARS in the post-outbreak period

From: Subject: WHO: Alert, verification and public health management of SARS in the post-outbreak period Date: Fri, 12 Sep 2003 18:33:28 +0300 MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_000_0032_01C3795C.5BE8C740"; type="text/html" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2800.1165 This is a multi-part message in MIME format. ------=_NextPart_000_0032_01C3795C.5BE8C740 Content-Type: text/html; charset="utf-8" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.who.int/csr/sars/postoutbreak/en/ =EF=BB=BF WHO: Alert, verification and public health management = of SARS in the post-outbreak period

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Location: WHO > WHO sites = > CSR=20 Home > Severe = Acute=20 Respiratory Syndrome (SARS) =

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Alert, verification and public health management of SARS = in the=20 post-outbreak period

14 August 2003 =

Rationale for=20 continued vigilance for SARS

First recognized as = a=20 global threat in mid-March 2003, Severe Acute Respiratory = Syndrome=20 (SARS) was successfully contained in less than four months. = On 5=20 July 2003, WHO reported that the last human chain of = transmission of=20 SARS had been broken.

While much has been learned about this = syndrome since=20 March 2003, including its causation by a new coronavirus = (SARS-CoV),=20 our knowledge about the epidemiology and ecology of SARS = coronavirus=20 infection and of this disease remains limited. Resurgence of = SARS=20 remains a distinct possibility and does not allow for=20 complacency.

In the post-outbreak period, all countries = must remain=20 vigilant for the recurrence of SARS and maintain their = capacity to=20 detect and respond to the re-emergence of SARS should it = occur. The=20 WHO case definitions during the outbreak period relied = heavily on=20 epidemiological criteria to increase the specificity of = syndromic=20 clinical criteria for atypical pneumonia or respiratory = distress=20 syndrome (RDS). However, epidemiological links to cases of = SARS and=20 areas reporting recent local transmission are no longer of = use in=20 helping to define incident cases. Furthermore, the = non-specific=20 clinical features of SARS, the lack of a current rapid = diagnostic=20 test that can reliably detect SARS-CoV in the first few days = of=20 illness, and the seasonal occurrence of other respiratory = diseases,=20 including influenza, may confound any surveillance for SARS = or=20 demand a level of quality and intensity which few health = care system=20 worldwide can sustain. Even with the most sophisticated = surveillance=20 systems, the first case of SARS in the post-outbreak period = may=20 escape early detection.

This document describes a SARS alert = mechanism for the=20 post-outbreak period. It provides guidance for managing a = SARS=20 "alert" through to laboratory confirmation or exclusion of = persons=20 under investigation as SARS cases. The document does not = address=20 complex surveillance issues or case categorization for = SARS.

It also provides guidance to clinicans on = the clinical=20 presentation, laboratory and radiological findings to assist = in=20 diagnosis of SARS and in decisions to implement = transmission-based=20 infection control.

For additional information on the previous = SARS=20 outbreak, please also refer to SARS: = breaking the=20 chains of transmission

2. Risk assessment

Ideally, = each Member=20 State should determine the intensity of its surveillance for = SARS in=20 the post-outbreak period on the basis of a risk assessment. = WHO has=20 defined three major areas that take into account the = experience=20 during the recent outbreak of SARS and the potential for=20 resurgence:

Potential zone of re-emergence of=20 SARS-CoV

Identified as source(s) of the previous outbreak in = November=20 2002 or areas with an increased likelihood of animal to = human=20 transmission of SARS-CoV infection.=20

Nodal areas

Sustained local transmission experienced during the = previous=20 outbreak or entry of large numbers of persons from the = potential=20 zone of re-emergence of SARS-CoV.

Low risk areas

Never reported cases, reported only imported cases or=20 experienced only limited local transmission during the = previous=20 outbreak.

Thus, WHO recommends a staged approach to=20 surveillance:

Potential zone of re-emergence of = SARS

SARS Alert AND
enhanced surveillance for SARSAND
special studies for SARS-CoV infections in animal and = human=20 populations

Nodal areas

SARS Alert AND
enhanced surveillance for SARS

Low risk areas

Surveillance for clusters of "alert" cases among = health care=20 workers, other hospital staff, patients and visitors in = the same=20 health care unit (see section 3 =E2=80=93 The SARS Alert) =

3. The SARS Alert

The SARS Alert is an operational definition = to ensure=20 that appropriate infection control and public health = measures are=20 implemented until SARS has been ruled out as a cause of the = atypical=20 pneumonia or RDS.

3.1 Objectives of the SARS Alert

Provide early warning of the potential recurrence of = SARS to:=20
- rapidly implement appropriate infection control = measures=20
- expedite diagnosis=20
- activate the public health response
Raise a global alert if indicated

Definition of a SARS Alert=20

Two or more health care workers in the same = health=20 care unit fulfilling the clinical case definition of SARS = (see=20 section 3.3) and with onset of illness in the same 10-day=20 period.

Hospital acquired illness in three or more = persons=20 (health care workers and/or other hospital staff and/or = patients=20 and/or visitors) in the same health care unit fulfilling the = clinical case definition of SARS (see section 3.3) and with = onset of=20 illness in the same 10-day period.

A jurisdiction may chose, based on its = experience, to=20 increase the minimum number of "alert" cases defining a = cluster. The=20 definition of the health care unit in which the cluster = occurs will=20 depend on the local situation. Unit size may range from an = entire=20 health care facility if small, to a single department or = ward of a=20 large tertiary hospital.

3.2 Case description of SARS =

See Annex 1 Clinical description of SARS. = The case=20 description provides details of the clinical evolution of = SARS and=20 radiological and laboratory findings to assist clinicians = with its=20 diagnosis. It provides information on the spectrum of the = disease,=20 including atypical presentations.

3.3 Case Definitions

Clinical case definition of SARS
The = following=20 clinical case definition has been developed for public = health=20 purposes.

A person with a history of:

Fever (=E2=89=A5 38=C2=B0C)

AND One or more symptoms of lower = respiratory=20 tract illness (cough, difficulty breathing, shortness of = breath)

AND

Radiographic evidence of lung infiltrates = consistent=20 with pneumonia or RDS OR autopsy findings consistent = with the=20 pathology of pneumonia or RDS without an identifiable = cause.

AND
No alternative diagnosis can = fully=20 explain the illness.

Laboratory case definition of SARS =

A person with symptoms and signs that are = clinically=20 suggestive of SARS AND with positive laboratory = findings for=20 SARS-CoV based on one or more of the following diagnostic=20 criteria:

a) PCR positive for SARS-CoV
PCR = positive=20 using a validated method from:

At least two different clinical specimens (eg = nasopharyngeal=20 and stool) OR=20
The same clinical specimen collected on two or more = occasions=20 during the course of the illness (eg sequential = nasopharyngeal=20 aspirates) OR=20
Two different assays or repeat PCR using a new RNA = extract=20 from the original clinical sample on each occasion of = testing.=20

b) Seroconversion by ELISA or IFA

Negative antibody test on acute serum followed by = positive=20 antibody test on convalescent phase serum tested in = parallel=20 OR=20
Fourfold or greater rise in antibody titre between = acute and=20 convalescent phase sera tested in parallel.

c) Virus isolation

Isolation in cell culture of SARS-CoV from any = specimen=20 AND PCR confirmation using a validated method. =

Testing should only be undertaken in a = national or=20 regional reference laboratory as per WHO recommendations (Use of = laboratory=20 methods for SARS diagnosis ). WHO will assist resource = poor=20 countries to confirm their first cases of SARS through = laboratory=20 collaboration.

3.4 Public health management of a SARS = Alert=20

When a SARS Alert is raised:
1. = Patient(s)=20 should be immediately isolated and transmission-based = precautions=20 instituted, if not already in place (see = clinical=20 management guidelines )

2. The diagnosis should be expedited (see = Annex 2=20 Guidance regarding the diagnosis of SARS in the = post-outbreak period=20 =E2=80=93 A concern for all health care workers). WHO will = assist in the=20 investigation of SARS alerts as appropriate, including the=20 facilitation of access to laboratory services (see Annex 3 = WHO Focal=20 Points for SARS).

3. Contacts of persons under investigation = for SARS=20 should be traced and quarantined until SARS has been = ruled out as=20 the cause of the illness .

3.2 Individuals with risky exposures to a = person or=20 persons in a SARS alert cluster should be managed as = contacts=20 until SARS has been ruled out as the cause of the = illness.

3.3 Contact within the health care setting = should be=20 managed in the following way:

Inpatient contacts should be isolated or cohorted = away from=20 unexposed patients and transmission-based precautions=20 instituted. They should be placed on fever surveillance. =
Exposed staff should be placed on active fever = surveillance,=20 and either cohorted to care for exposed patients (as = above) or=20 placed on home quarantine depending on local = circumstances.=20

3.4 Community contacts should be:

Given information on the clinical picture, = transmission,=20 etc. of SARS=20
Placed under active surveillance for 10 days and = voluntary=20 home quarantine recommended=20
Visited or telephoned daily by a member of the = public health=20 care team=20
Temperature recorded daily.=20
If the contact develops disease symptoms, they = should be=20 investigated locally at an appropriate health care = facility.=20
The most consistent first symptom that is likely to = appear=20 is fever.

3.5 National public health authorities = should report=20 every laboratory confirmed case of SARS to WHO (see = below).

International reporting of SARS

A new outbreak of SARS is defined as the = occurrence of=20 one or more clinically compatible, laboratory-confirmed = cases of=20 SARS in any country based on definitive laboratory = investigations.=20 The reappearance of SARS in the human population would be = considered=20 a global public health emergency.

For the purposes of the international = reporting of=20 SARS in the post-outbreak period, Member States are = requested to=20 inform WHO of laboratory-confirmed cases only.

Laboratory confirmed cases of SARS could be = detected=20 through a SARS alert verification process but also as = sporadic=20 case(s) of acute respiratory illness on which SARS-CoV = testing was=20 undertaken (i.e. fulfil the case definition described in = section=20 3.3). Reporting to WHO should include both of these = scenarios but=20 should exclude asymptomatic persons with a positive=20 laboratory test or symptomatic persons without laboratory=20 confirmation. No nil reporting is required.

WHO requests that Members States immediately = inform=20 the focal points at Regional Offices or Headquarters of = every person=20 meeting the laboratory-confirmed case definition of SARS = (see Annex=20 3 WHO Focal Points for SARS). This will allow WHO to assess = the need=20 for a global alert and re-institute global surveillance for = SARS on=20 the basis of that notification as appropriate.

The development of new case definitions = applicable to=20 the new situation, surveillance standards and a step-down = strategy=20 may be required once laboratory-confirmed cases have been=20 reported.

In the event of an international traveller = being=20 investigated for SARS, all Member States involved in = international=20 contact tracing around the case(s) should communicate = directly with=20 each other during the investigation. WHO should be informed = only=20 when the incident is laboratory confirmed.

WHO will continue to identify and verify = rumours of=20 events of international public health concern, including = rumours=20 about SARS, through its usual well-established = mechanisms.

Indicators of the quality of the SARS = alert=20 mechanism

WHO recommends that national public health = authorities=20 monitor the quality of the SARS alert mechanism, e.g. by=20 establishing indicators based on:

the number of alerts expected and reported by health=20 facilities over time=20
the time taken to implement transmission-based = precautions and=20 expedite diagnosis=20
the time taken to alert local public health = authorities,=20 national public health authorities=20
the time taken to complete contact tracing and = quarantine=20 contacts.

This list is not meant to be exhaustive but = rather a=20 suggested approach to monitoring the alert mechanism.

4. Enhanced surveillance and special = studies for=20 SARS-CoV infections in animal and human populations

Jurisdictions in nodal areas and areas of = potential=20 re-emergence have maintained heightened SARS surveillance=20 established during the outbreak period, and continue doing = so for=20 the foreseeable future. WHO will encourage these = jurisdictions to=20 make available to the global community the details of these=20 surveillance activities and will offer its assistance in = summarizing=20 and updating available information on its web site.

Depending on risk assessment and available = resources,=20 nodal areas and areas of potential re-emergence may include = one or=20 more of the following activities:

Surveillance for atypical pneumonia in settings such = as=20 nursing homes, rehabilitation units, community health care = centres=20 and in private practice (see Annex, Guidance regarding the = diagnosis of SARS in the post-outbreak period - A concern = for all=20 health care workers)=20
Surveillance of persons discharged from hospital with = a=20 diagnosis of unspecified atypical pneumonia=20
Surveillance for absenteeism among health care workers =
Laboratory-based surveillance of SARS-CoV infection=20
Surveillance for requests for laboratory testing of=20 respiratory pathogens or SARS-CoV=20
Surveillance for unexplained deaths following an acute = respiratory illness=20
Serological surveillance of high risk populations = (health care=20 workers, animal handlers, market vendors, hunters, etc)=20
Community-based serological surveys to monitor changes = in the=20 seroprevalence of SARS-CoV infection=20
Serosurveys among animal populations.

This list is not meant to be exhaustive but = rather a=20 suggested approach to enhanced surveillance.=20

Annex 1 Clinical case description of = SARS=20

Aetiology

Severe acute respiratory syndrome (SARS) is = a disease=20 caused by SARS coronavirus (SARS-CoV).

Epidemiology

Nosocomial transmission of SARS CoV has been = a=20 striking feature of the SARS outbreak. The majority of the = cases are=20 adults. Children are rarely affected.

The mean incubation period is 5 days with = the range of=20 2-10 days although there are isolated reports of longer = incubation=20 periods. There have been no reports of transmission = occurring before=20 the onset of symptoms.

Natural history of the disease =

Week 1 of illness

Patients initially develop influenza-like = prodromal=20 symptoms. Presenting symptoms include fever, malaise, = myalgia,=20 headache, and rigors. No individual symptom or cluster of = symptoms=20 has proven specific. Although history of fever is the most=20 frequently reported symptom, it may be absent on initial=20 measurement.

Week 2 of illness

Cough = (initially=20 dry), dyspnoea and diarrhoea may be present in the first = week but=20 more commonly reported in the second week of illness. Severe = cases=20 develop rapidly progressing respiratory distress and oxygen=20 desaturation with about 20% requiring intensive care. Up to = 70% of=20 the patients develop diarrhoea which has been described as = large=20 volume and watery without blood or mucus. Transmission = occurs mainly=20 during the second week of illness.

Clinical outcomes

Based on an analysis of data from Canada, = China, Hong=20 Kong SAR, Singapore, Viet Nam and the United States the case = fatality ratio (CFR) of SARS is estimated to range from 0% = to more=20 than 50% depending on the age group affected, with an = overall CFR=20 estimate of approximately 11% (see Update 49=20 - SARS case fatality ratio, incubation period ). Higher=20 mortality has also been associated with male sex and = presence of=20 co-morbidity in various studies.

Elderly and paediatric cases and SARS = in=20 pregnancy

Atypical presentations such as afebrile = illness or=20 concurrent bacterial sepsis/pneumonia have been highlighted = as a=20 particular problem in the elderly. Underlying chronic = conditions and=20 their more frequent use of health facilities have both = contributed=20 to initially unrecognized nosocomial transmission = events.

SARS occurred less frequently and was = observed to be a=20 milder illness in the paediatric population.

Known cases of SARS in pregnancy have = suggested an=20 increase in fetal loss in early pregnancy and maternal = mortality in=20 later pregnancy.

Radiological findings

Early chest radiograph or CT changes are = observed in=20 most of the patients as early as days 3-4 of illness in = spite of the=20 absence of respiratory signs. These typically show patchy=20 consolidation starting with a unilateral peripheral lesion = which=20 progress to multiple lesions or ground glass appearance. = Some=20 lesions follow a shifting pattern. Features during the later = stages=20 have sometimes included spontaneous pneumothorax, = pneumomediastinum,=20 sub-pleural fibrosis and/or cystic changes.

Haematological and biochemical = findings=20

There are no haematological or biochemical = parameters=20 specific for SARS; however, studies have consistently = highlighted=20 the following:

Haematological findings

Lymphopenia is common on presentation and = progresses=20 during the course of the illness. Sometimes thrombocytopenia = and=20 prolonged APTT are observed.

Biochemical findings

LDH is frequently high and some reports have = suggested=20 association with poor prognosis. ALT, AST and CPK elevation = are less=20 frequently reported. Abnormal serum electrolytes have also = been=20 reported on presentation or during hospitalization including = hyponatraemia, hypokalaemia, hypomagnesaemia and = hypocalcaemia.

Annex 2 Guidance regarding the diagnosis = of SARS in=20 the post-outbreak period =E2=80=93 A concern for all health = care workers=20 (HCW's)

Making a diagnosis of SARS sufficiently = early in the=20 disease to implement effective infection control and public = health=20 measures will prove a challenge that requires all HCWs to = always=20 incorporate risk-based infection control measures in care = provision.=20 This will only occur within a culture that treats infection=20 prevention and control as everyone=E2=80=99s responsibility. = All HCWs should=20 be encouraged to consider the possibility of SARS in a = patient under=20 their care. If there are features suggestive of SARS then = any=20 concerns should be raised promptly and trigger risk-based = infection=20 control measures. There must be monitoring and feedback on = this=20 process.

The non-specific nature of the presentation = of SARS=20 could lead to concern being raised in a vast number of = patients who=20 will ultimately prove to have another diagnosis. In = practice,=20 concern about the possibility of SARS may often be expressed = at the=20 stage where atypical pneumonia is suspected.

This process should not rely wholly on = clinicians but=20 should be responsive to the concerns raised by other = HCWs.

Concern of SARS raised by clinicians =

For clinicians the process of diagnosis from = initial=20 concern to confirmation or exclusion of a SARS diagnosis = (see case=20 description) is usually an incremental one following = sequential=20 information gathering from various sources that include:

clinical history=20
clinical examination=20
bedside monitoring=20
radiology investigations=20
haematology investigations=20
biochemistry investigations=20
microbiology and virology investigations=20
response to treatment=20
epidemiological information obtained from the = individual, the=20 health facility or the community.

Concern about SARS raised by other health = professionals

Concerns regarding SARS may be raised by any = HCW. All=20 HCW's need to ensure they are fully aware of what = constitutes a=20 clinical concern about SARS and how, in the course of their = duties=20 they could be involved in the presentation, investigation or = treatment of an unrecognized SARS case.

They should be encouraged to raise concerns = with both=20 the clinicians and infection control team who should provide = monitoring and feedback on the process.

Some examples are given:=20

infection control staff e.g. noting an increase in = hospital=20 acquired pneumonias=20
nursing staff e.g. noting a pattern of deterioration = in a=20 patient suggestive of SARS=20
staff involved in care of the elderly e.g. noting an = increase=20 in severe illness=20
occupational health staff e.g. noting staff sickness=20 compatible with atypical pneumonia=20
physiotherapists e.g. noting a pattern of atypical = pneumonia=20
radiographers e.g. noting a pattern of atypical = pneumonia=20
radiologists e.g. noting a pattern of atypical = pneumonia=20
haematologists e.g. noting a profile suggestive of = atypical=20 pneumonia=20
biochemists e.g. noting a profile suggestive of = atypical=20 pneumonia=20
microbiologists e.g. noting an increase in undiagnosed = pneumonias=20
virologists e.g. noting an increase in requests for=20 respiratory serology=20
pharmacists e.g. noting an increase in prescribing for = pneumonia

Atypical pneumonia

Common bacteria, such as Streptococcus=20 pneumoniae and Haemophilus influenzae cause = so-called=20 "typical pneumonia". Cases of typical pneumonia = present with=20 fever, respiratory symptoms (cough, which is usually early = in the=20 illness and often productive, shortness of breath etc.), = elevated=20 white cell count and well-defined changes on the chest = radiograph.=20 They tend to respond to antibiotic therapy for community = acquired=20 pneumonia.

In contrast, "atypical pneumonia" is defined = as=20 pneumonia or lower respiratory tract infection with an = atypical=20 presentation often with a gradual onset of symptoms such as=20 non-productive, dry cough, a variable white blood cell count = and the=20 chest radiograph changes. These include patchy, poorly = defined=20 changes, which may be often more severe than the clinical = picture=20 would suggest. The causative agents include, Mycoplasma=20 pneumoniae, Chlamydia spp., Legionella pneumophila, Coxiella = burnetii.

Diagnosis of atypical pneumonia is in itself = challenging but will be assisted by careful clinical = assessment=20 (including non-respiratory symptoms), and given the likely = absence=20 of auscultatory signs, accurate measurement of respiratory = rate and=20 oxygen saturation (where available) becomes even more = important.=20 Chest radiography is of great use in achieving diagnosis and = should=20 be considered even in the absence of respiratory signs.

Features of SARS that may commonly help = with=20 clinical diagnosis

SARS	Example	Caution
Clinical history	Sudden onset of flu-like prodrome, = dry cough,=20 non =E2=80=93respiratory symptoms e.g. diarrhoea = common	Take a travel history, history of=20 hospitalisation and history of contact with healthcare = facility. The absence of such a history should not=20 automatically exclude diagnosis of SARS.
Clinical examination	Does not correlate with chest = radiology=20 changes	Lack of respiratory signs = particularly in=20 groups such as the elderly
Bedside monitoring	Hypoxia	Temperature may not be elevated on = admission,=20 respiratory rate should be documented
Haematology investigations	Low lymphocyte count
Biochemistry = investigations	Raised LDH	Check profile for electrolytes and = liver=20 function
Radiology investigations	CXR changes poorly defined, patchy, = progressive changes	May present as a lobar pneumonia,=20 pneumothorax and pneumomediastinum may = occur
Microbiology = investigations	Investigate for community, and = hospital=20 acquired pneumonias including atypical = pneumonias	Concurrent infections may = occur
Virology investigations	Investigate for other causes of = atypical=20 pneumonia	Interpret SARS test results with=20 caution
Treatment	As yet there is not proven = treatment for=20 SARS, supportive measures are recommended	Lack of response to treatment with = standard=20 antibiotics for community acquired pneumonia including = atypical pneumonia may be indicative of=20 SARS

Annex 3 WHO Focal Points for SARS =

WHO Geneva
Dr. Angela Merianos,
CSR = SARS=20 Coordinator
E-mail: sars@who.int
Please use this = email=20 address for all SARS-related correspondence to WHO = Geneva.

WHO Regional Office for Africa (AFRO)
Dr = Paul=20 Lusamba-Dikassa,
Regional Adviser, Communicable Disease=20 Surveillance and Response
E-mail: = lusambap@whoafr.org

Regional Office for the Americas / Pan = American Health=20 Organization (AMRO/PAHO)
Dr Marlo Libel,
Regional = Adviser in=20 Communicable Diseases, Disease Prevention and Control =
E-mail:=20 libelmar@paho.org

Regional Office for the Eastern = Mediterranean (EMRO)=20
Dr Nadia Teleb,
Medical Epidemiologist
E-mail:=20 telebn@emro.who.int

Regional Office for Europe (EURO)
Dr = Bernardus=20 Ganter,
Regional Adviser, Communicable Diseases =
E-mail:=20 bga@who.dk

Regional Office for South-East Asia (SEARO) =
Dr=20 M.V.H. Gunaratne, Regional Adviser on Communicable Disease=20 Surveillance and Response
E-mail: gunaratnem@whosea.org=20

Regional Office for the Western Pacific (WPRO)
Dr = Hitoshi=20 Oshitani, Regional Adviser in Communicable Disease = Surveillance and=20 Response
E-mail: outbreak@wpro.who.int

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