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Severe Acute Respiratory Syndrome (SARS)

Reporting Information

Class A

Report a case, suspected case, and/or positive laboratory result immediately via telephone to the local public health department in which the patient resides.  If patient residence is unknown, report immediately via telephone to the local public health department in which the reporting healthcare provider or laboratory is located.  Local public health departments should report immediately via telephone the case, suspected case, and/or a positive laboratory result to the Ohio Department of Health (ODH).

Reporting Form(s) and/or Mechanism

Immediate telephone reporting is required.

The local public health department should enter the case into the Ohio Disease Reporting System (ODRS) within 24 hours after the telephone report.

The SARS Domestic Case Reporting Form (CDC OMB 0920-0008) is required for completion by the local public health department when following up with cases.  Do not send this form to ODH unless otherwise requested; information collected from the form should be entered into ODRS where fields are available, and the form should be uploaded in the Administration section of ODRS.

Key Fields for ODRS Reporting

  • Import status: whether the infection was travel-associated or Ohio-acquired.
  • Date of illness onset.
  • All fields in the Epidemiology module.

Agent

SARS-associated coronavirus (SARS-CoV) a species of Coronaviridae.

Case Definition

Clinical Description

Early Illness

Presence of two or more of the following features: fever (might be subjective), chills, rigors, myalgia, headache, diarrhea, sore throat, or rhinorrhea.

Mild-to-Moderate Respiratory Illness

  • Temperature of >100.4°F (>38°C)* AND
  • One or more clinical findings of lower respiratory illness (e.g., cough, shortness of breath, or difficulty breathing).

Severe Respiratory Illness

  • Meets clinical criteria of mild-to-moderate respiratory illness AND
  • One or more of the following findings:
    • Radiographic evidence of pneumonia OR
    • Acute respiratory distress syndrome OR
    • Autopsy findings consistent with pneumonia or acute respiratory distress syndrome without an identifiable cause.

Laboratory Criteria for Diagnosis

Tests to detect SARS-CoV are being refined and their performance characteristics assessed*; therefore, criteria for laboratory diagnosis of SARS-CoV are changing.  The following are general criteria for laboratory confirmation of SARS-CoV:

  • Detection of serum antibody to SARS-CoV by a test validated by the Centers for Disease Control and Prevention (CDC) (e.g., enzyme immunoassay) OR
  • Isolation in cell culture of SARS-CoV from a clinical specimen OR
  • Detection of SARS-CoV RNA by a reverse transcription polymerase chain reaction test validated by CDC and with subsequent confirmation in a reference laboratory (e.g., CDC).

Information about the current criteria for laboratory diagnosis of SARS-CoV is available at CDC's SARS website.

Exposure

Possible Exposure to SARS-Associated Coronavirus (SARS-CoV)

One or more of the following exposures 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.

Case Classification

Probable

Meets the clinical criteria for severe respiratory illness and the epidemiologic criteria for likely exposure to SARS-CoV.

Confirmed

Clinically compatible illness (i.e., early, mild-to-moderate, or severe) that is laboratory confirmed.

Exclusion Criteria

A case may be excluded as a SARS report under investigation (SARS RUI), including as a CDC-defined probable SARS-CoV case, if any of the following apply:

  • An alternative diagnosis can explain the illness fully* OR
  • Antibody to SARS-CoV is undetectable in a serum specimen obtained >28 days after onset of illness* OR
  • The case was reported on the basis of contact with a person who was excluded subsequently as a case of SARS-CoV disease; then the reported case also is excluded, provided other epidemiologic or laboratory criteria are not present.

SARS Report 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.

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.

* For notes that go with this case definition, see CDC's case definition for SARS-CoV.

Signs and Symptoms

In general, SARS begins with a high fever (temperature >100.4°F [>38.0°C]).  Other symptoms may include headache, an overall feeling of discomfort, and body aches.  Some people experience mild respiratory symptoms with the onset of symptoms, while others develop a dry, nonproductive cough after 2-7 days.  These symptoms might be accompanied by or progress to a condition in which the oxygen levels in the blood are low (hypoxia).  Respiratory symptoms are usually progressive; almost all SARS patients have radiographic evidence of pneumonia by the sixth day of illness and in most cases lymphopenia.  About 10-20% percent of patients have diarrhea.

Diagnosis

Initial diagnostic testing for suspected SARS patients should include chest radiograph, pulse oximetry, blood cultures, sputum Gram stain and culture, and testing for viral respiratory pathogens, notably influenza A and B and respiratory syncytial virus (RSV).  A specimen for Legionella and pneumococcal urinary antigen testing should also be considered.  Clinicians should save any available clinical specimens (e.g., sputum, serum) for additional testing until a specific diagnosis is made.  Acute and convalescent (>28 days after onset of symptoms) serum samples should be collected from each patient who meets the SARS case definition.

In the absence of person-to-person transmission of SARS-CoV anywhere in the world, healthcare providers should ask all people hospitalized with chest x-ray-confirmed pneumonia three key screening questions:

  1. "Do you have a history of recent travel (within 10 days) to a SARS-affected area or close contact with ill persons with a history of travel to such areas?"
  2. "Are you employed as a healthcare worker with direct patient contact or work in a laboratory where exposure to SARS-CoV is possible?"
  3. "Do you have close contacts that have been told they have pneumonia and the cause of pneumonia has not yet been determined?"

If the answer to any of the three screening questions is "Yes," healthcare providers will need to:

  1. Institute droplet and airborne precautions with goggles.
  2. Notify the local health department.
  3. Consider SARS testing if no alternative diagnosis is found within 72 hours.

Epidemiology

Source

The Himalayan masked palm civet was the main source of the SARS virus in the 2002-2003 outbreak.  Similar coronaviruses were isolated from other wildlife species, including bats.  A lab accident or undetected transmission in humans may be other potential sources of the virus.

Occurrence

Currently, there are no known cases of person-to-person transmission of SARS-CoV worldwide.

However, during November 2002-July 2003, a total of 8,098 probable SARS cases were reported to the World Health Organization (WHO) from 29 countries, including 29 cases from the United States; 774 SARS-related deaths were reported, none of which occurred in the United States.  Eight United States cases had serologic evidence of SARS-CoV infection.  A total of 156 reported SARS cases in the United States from the 2003 epidemic remain under investigation, with 137 (88%) cases classified according to previous surveillance criteria as suspected SARS and 19 (12%) classified as probable SARS.  Because convalescent serum specimens have not been obtained from the 19 probable and 137 suspect cases that remain under investigation, whether these persons had SARS-CoV disease is unknown.

In 2003, 16 suspect and 1 probable SARS cases were reported in Ohio.  Serologic evidence of infection was not detected in any of these cases.

Since 2004, there have not been any known cases of SARS reported anywhere in the world.  The content in the CDC website (and the IDCM) was developed for the 2003 SARS epidemic.  But, some guidelines are still being used.  Any new SARS updates will be posted on the IDCM website.

Mode of Transmission

The main way that SARS seems to spread is by close person-to-person contact.  The virus that causes SARS is thought to be transmitted most readily by respiratory droplets (i.e., droplet spread) produced when an infected person coughs or sneezes.  Droplet spread can happen when droplets from the cough or sneeze of an infected person are propelled a short distance (generally up to 3 feet) through the air and are deposited on the mucous membranes of the mouth, nose, or eyes of persons who are nearby.  The virus also can spread when a person touches a surface or object contaminated with infectious droplets and then touches his or her mouth, nose, or eye(s).  In addition, it is possible that the SARS virus might spread more broadly through the air (i.e., airborne transmission) or by other ways that are not now known.

Period of Communicability

Available information suggests that people with SARS are most likely to be infectious only when they have symptoms, such as fever or cough.  However, as a precaution against spreading the disease, CDC recommends that people with SARS limit their interactions outside the home (e.g., not going to work, not going to school) until 10 days after their symptoms have gone away.  Patients are most infectious during the second week of illness.

Incubation Period

2-10 days, most commonly 4-6 days.

Public Health Management

Case

Investigation

Obtain information about the patient's occupation, history of travel outside the United States, contact with suspected or confirmed SARS case, or close contact with an ill individual who traveled to a SARS-affected area within 10 days of illness onset.

Treatment

No specific treatment recommendations can be made at this time.  Empiric therapy should include coverage for organisms associated with any community-acquired pneumonia of unclear etiology, including agents with activity against both bacterial and viral respiratory pathogens.  Treatment choices may be influenced by severity of the illness.  Infectious disease consultation is recommended.

Isolation and Follow-Up Specimens

Ohio Administrative Code (OAC) 3701-3-13 (V) states:

"SARS (Severe Acute Respiratory Distress Syndrome): a person with confirmed or suspected SARS shall be placed in airborne isolation until no longer considered infectious."

Clinicians evaluating suspected cases should use standard precautions (e.g., hand hygiene) together with airborne precautions (e.g., N- 95 respirator) and contact precautions (e.g., gowns, gloves).  Until the mode of transmission has been defined more precisely, eye protection also should be worn for all patient contact.  A person with confirmed or suspected SARS shall be placed in airborne isolation until no longer considered infectious.

Contacts

ODH does not recommend the quarantine of asymptomatic individuals who have had exposure to SARS.  ODH recommends isolation of all persons known or suspected as having SARS and persons exhibiting symptoms of respiratory illness clinically consistent with SARS who have also been identified as having close contact to a known or suspect SARS case.

Persons who may have been exposed to SARS should be vigilant for fever (i.e., measure temperature twice daily) and respiratory symptoms over the 10 days following exposure.  During this time, in the absence of both fever and respiratory symptoms, persons who may have been exposed to SARS patients need not limit their activities outside the home and should not be excluded from work, school, out-of-home child care, church, or other public areas.

Exposed persons should notify their healthcare provider immediately if fever or respiratory symptoms develop.  Exposed persons should also notify their healthcare provider when they will be arriving at the healthcare facility for evaluation so arrangements can be made to prevent any possible transmission of SARS to individuals in the healthcare setting.

Symptomatic persons exposed to SARS should follow the following infection control precautions:

  • If fever or respiratory symptoms develop, the person should limit interactions outside the home and not go to work, school, out-of-home child care, church, or other public areas.  In addition, the person should use infection control precautions in the home to minimize the risk for transmission, and he/she should continue to measure his/her temperature twice daily.
  • If symptoms improve or resolve within 72 hours after first symptom onset, the person may be allowed, after consultation with local public health authorities, to return to work, school, out-of-home child care, church, or other public areas and infection control precautions can be discontinued.
  • For persons who meet or progress to meet the case definition for suspected SARS (i.e., develop fever and respiratory symptoms), infection control precautions should be continued until 10 days after the resolution of fever, provided respiratory symptoms are absent or improving.
  • If the illness does not progress to meet the case definition, but the individual has persistent fever or unresolving respiratory symptoms, infection control precautions should be continued for an additional 72 hours, at the end of which time a clinical evaluation should be performed.
  • If the illness progresses to meet the case definition, infection control precautions should be continued as described above.  If case definition criteria are not met, infection control precautions can be discontinued after consultation with local public health authorities and the evaluating clinician.  Factors that might be considered include the nature of the potential exposure to SARS, the nature of contact with others in the residential or work setting, and any evidence for an alternative diagnosis.

Laboratory Criteria for Diagnosis

CDC has developed and validated an enzyme immunoassay (EIA) and a reverse transcription-polymerase chain reaction (RT-PCR) test for the detection of SARS-CoV.  The EIA has been distributed to most state public health laboratories and the RT-PCR has been distributed to most laboratories in the Laboratory Response Network (LRN).  Both the EIA and the RT-PCR tests are sensitive and highly specific for SARS-CoV.  The ability to diagnose SARS-CoV infection in a patient is often limited, however, by either the low concentration of virus in most clinical specimens (RT-PCR assays) or the time it takes a person to mount a measurable antibody response to SARS-CoV (serologic assays).  The likelihood of detecting infection is increased if multiple specimens (e.g., stool, serum, respiratory tract specimens) are collected at several times during the course of illness.

CDC considers detection of SARS-CoV antibody to be the most reliable indicator of infection.  Since previous infection is still rare in most populations, seroconversion is not needed to diagnose infection.  Therefore, the presence of SARS-CoV antibody in someone without a previous history of SARS is indicative of recent infection.  A negative serologic test can rule-out SARS-CoV infection if the serum specimen is collected >28 days after onset of illness.  Some persons do not mount an antibody response (i.e., test positive) until more than 28 days after onset of illness.  Patients with a negative antibody test result whose specimens were obtained 28 days before illness onset or before should have another serum specimen collected >28 days after onset of symptoms.

RT-PCR for SARS-CoV RNA is a very sensitive and specific assay when performed appropriately.  This test can detect SARS-CoV RNA in serum, stool, upper and lower respiratory specimens, various tissues, and occasionally urine specimens.  Testing of multiple specimen types at several times during the course of illness should increase the likelihood of detecting infection.

See the CDC's SARS website for additional information on lab tests.

Exclusion Criteria

A person may be excluded as a SARS report under investigation (SARS RUI), including as a CDC-defined probable SARS-CoV case, if any of the following applies:

  • An alternative diagnosis can explain the illness fully.
  • Antibody to SARS-CoV is undetectable in a serum specimen obtained >28 days after onset of illness.
  • The case was reported on the basis of contact with a person who was subsequently excluded as a case of SARS-CoV disease.  Then the reported case also is excluded, provided other epidemiologic or laboratory criteria are not present.

 

Revised 12/2019.