Public Health Guidance for Community-Level Preparedness and Response to
Severe Acute Respiratory Syndrome (SARS) Version 2

Supplement B: SARS Surveillance

IV\. Plan for Surveillance of Cases of SARS-CoV Disease

## A. Surveillance in the Absence of Person-to-Person Transmission of SARS-CoV in the World

> **Objective:** Establish surveillance aimed at early detection of
> cases and clusters of severe unexplained respiratory infections (i.e.,
> pneumonia) that might signal the re-emergence of SARS-CoV.

Continued vigilance is critical to ensure the rapid recognition and
appropriate management of SARS patients if person-to-person SARS-CoV
transmission recurs. In the absence of known areas with SARS-CoV
transmission, the likelihood that a patient with fever or respiratory
symptoms has SARS-CoV disease will be exceedingly low unless the patient
has both typical clinical findings and some accompanying epidemiologic
evidence that raises the suspicion of exposure to SARS-CoV. Therefore,
U.S. surveillance efforts should focus on specific clinical syndromes
(i.e., cases of pneumonia requiring hospitalization) in groups likely to
be first affected by the re-emergence of SARS-CoV (e.g., travelers to
areas previously affected with SARS-CoV; healthcare workers).

> The 2003 SARS-CoV outbreak likely originated in mainland China, and
> neighboring areas such as Taiwan and Hong Kong are thought to be at
> higher risk due to the large volume of travelers from mainland China.
> Although less likely, SARS-CoV may also reappear from other previously
> affected areas. Therefore, clinicians should obtain a complete travel
> history. If clinicians have concerns about the possibility of SARS-CoV
> disease in a patient with a history of travel to other previously
> affected areas (e.g., while traveling abroad, had close contact with
> another person with pneumonia of unknown etiology or spent time in a
> hospital in which patients with acute respiratory disease were
> treated), they should contact the health department.
>
> In the absence of SARS-CoV transmission in the world, the screening of
> persons requiring hospitalization for radiographically confirmed
> pneumonia for risk factors suggesting SARS-CoV exposure should be
> limited to adults, unless there are special circumstances that make
> the clinician and public health personnel consider a child to be of
> potentially high risk for having SARS-CoV disease. During the 2003
> global outbreaks, infants and children accounted for only a small
> percentage of SARS cases and had a much milder disease and better
> outcome than adults. Although information on SARS-CoV disease in
> pediatric patients is limited, the role of children in transmission is
> likely much less significant than the role of adults.
>
> []{.mark}
>
> **Activities: Healthcare providers**

-   Consider SARS-CoV disease in patients who require hospitalization
    for radiographically confirmed pneumonia (or acute respiratory
    distress syndrome) of unknown etiology *and* who have one of the
    following risk factors in the 10 days before illness onset:

    -   Travel to mainland China, Hong Kong or Taiwan, or close
        contact[^1] with an ill person with a history of recent travel
        to one of these areas, *or*

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    -   Employment in an occupation associated with a risk for SARS-CoV
        exposure (e.g., healthcare worker with direct patient contact;
        worker in a laboratory that contains live SARS-CoV [^2]), *or*

    -   Part of a cluster of cases of atypical pneumonia without an
        alternative diagnosis

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-   Use SARS-CoV testing judiciously and in consultation with local or
    state public health officials, given that: 1) the positive
    predictive value of a positive laboratory test in the absence of
    SARS-CoV transmission is extremely low, and 2) false-positive tests
    may generate tremendous anxiety and concern and expend valuable
    public health resources.

-   Be alert for clusters of unexplained pneumonia among two or more
    healthcare workers who work in the same facility.

-   *Report* to the state or local health department:

    -   All persons requiring hospitalization for radiographically
        confirmed pneumonia who report at least one of the three risk
        factors listed above

    -   Any clusters of unexplained pneumonia requiring hospitalization,
        especially among healthcare workers

    -   Any positive SARS-CoV test result (requires immediate
        notification of the health department by telephone).

> **Activities: State and local health departments**

-   Disseminate surveillance guidelines regarding timely recognition,
    evaluation, and reporting of possible SARS-CoV cases to healthcare
    providers, particularly triage, emergency department, and
    hospital-based providers.

-   Establish a surveillance system to receive reports of:

    -   Persons who require hospitalization for radiographically
        confirmed pneumonia and who are found to be at greater risk for
        SARS-CoV disease based on the provider-based screening described
        above,

    -   Clusters of persons with unexplained pneumonia, and

    -   Positive SARS-CoV test results.

-   Review and obtain information needed to assess reported pneumonia
    cases and clusters for the likelihood of SARS-CoV disease.
    Considerations that increase the likelihood of SARS-CoV disease
    include:

    -   Illness onset dates grouped within a 10-day period

    -   Ill travelers who had contact with healthcare settings or
        persons hospitalized for unexplained respiratory infection while
        abroad and within 10 days of illness onset

    -   Clusters of pneumonia among any group of persons for whom
        alternative diagnoses have been reliably excluded or clusters in
        which one case is linked to travel to a previously affected area
        or to an ill healthcare worker

-   Review reports of persons who are hospitalized for pneumonia and are
    at increased risk for SARS-CoV disease to ensure that:

    -   Adequate testing is done to rule out other infectious causes of
        pneumonia

    -   SARS-CoV testing is ordered only when appropriate (see *Clinical
        Guidance on the Identification and Evaluation of Possible
        SARS-CoV Disease among Persons Presenting with
        Community-Acquired Illness*,
        [www.cdc.gov/ncidod/sars/clinicalguidance.htm](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).

-   Consult CDC as needed about cases or clusters of special concern.

-   Report to CDC any positive SARS-CoV test results.

-   Inform CDC of other cases or clusters of pneumonia that are of
    particular concern by calling 770-488-7100.

> **Activities: CDC**

-   Provide guidance to health departments, hospitals, and healthcare
    providers on SARS surveillance.

-   Assist state and local health departments in the development of an
    electronic reporting system and related forms to facilitate uniform
    reporting.

-   Assist states, as requested, in investigations of cases and clusters
    of persons with possible SARS-CoV disease.

-   Collect and review reports of pneumonia requiring hospitalization in
    travelers and clusters of healthcare workers associated with a high
    index of suspicion for SARS-CoV disease, as specified in the
    preceding section.

## B. Surveillance in the Presence of Person-to-PersonTransmission of SARS-CoV in the World

> **Objective:** Establish surveillance to promptly identify and report
> all new U.S. cases of SARS-CoV disease to facilitate outbreak
> management and control.
>
> If person-to-person SARS-CoV transmission is documented in the United
> States or abroad, the likelihood that a person with fever or lower
> respiratory symptoms might be infected with SARS-CoV will increase but
> will remain low unless the person has a history of recent exposure to
> a known case of SARS-CoV disease or to a setting in which SARS-CoV
> transmission is occurring. Surveillance efforts should be modified to
> incorporate available risk factor information, particularly regarding
> geographic transmission patterns. The scope of surveillance activities
> in specific communities may differ substantially depending on the
> extent of disease in both the community and local healthcare
> facilities or institutions. Ongoing analysis of surveillance data and
> other information will be critical to inform decisions about the need
> to implement or discontinue various elements of enhanced surveillance.
>
> Surveillance activities should also be enhanced or accelerated as
> needed by a particular community or institution. *Basic surveillance
> activities* should be initiated in areas with no or little SARS-CoV
> transmission and continued in areas with increased transmission.
> *Enhanced surveillance activities* should be considered if a community
> or facility experiences a significant increase in number of cases, if
> epidemiologic links between cases cannot be readily established, or if
> changing transmission patterns are identified. Enhanced surveillance
> activities should focus both on increasing the sensitivity of case
> detection through use of less specific clinical criteria when
> screening cases (see note below) and on evaluation of suspicious
> illnesses regardless of identification of an epidemiologic link.
>
> **NOTE:**  For persons with a high risk of exposure to SARS-CoV (e.g.,
> persons previously identified through contact tracing or
> self-identified as close contacts of a laboratory-confirmed case of
> SARS-CoV disease; persons who are epidemiologically linked to a
> laboratory-confirmed case of SARS-CoV disease), respiratory symptoms
> used to screen patients should be expanded to include upper
> respiratory symptoms such as sore throat and rhinorrhea, in addition
> to any other early non-respiratory symptoms of SARS-CoV disease such
> as chills, rigors, myalgia, headache, or diarrhea. The more common
> early symptoms include chills, rigors, myalgia, and headache; in some
> patients, myalgia and headache may precede the onset of fever by 12-24
> hours. However, diarrhea, sore throat, and rhinorrhea may also be
> early symptoms of SARS-CoV disease.
>
> **Activities: Healthcare providers**
>
> ***Community-based surveillance***
>
> [Basic Activities]{.underline}

-   Continue case detection and reporting as detailed above (absence of
    SARS-CoV transmission in the world) to identify potential SARS cases
    with no known epidemiologic links.

-   Consider screening all patients presenting to outpatient clinics
    with a fever or lower respiratory symptoms for SARS risk factors.
    SARS risk factors include:

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-   Travel within 10 days of illness onset to a foreign or domestic
    location with documented or suspected transmission of SARS-CoV (see
    [www.cdc.gov/ncidod/sars/travel.htm](http://www.cdc.gov/ncidod/sars/travel.htm)),
    *or*

-   Close contact within 10 days of illness onset with a person with
    known or possible SARS-CoV disease.

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-   If a patient with a fever or evidence of respiratory illness has a
    SARS risk factor, notify the local health department, and evaluate
    and isolate the patient according to the algorithm in *Clinical
    Guidance on the Identification and Evaluation of Possible SARS-CoV
    Disease among Persons Presenting with Community-Acquired Illness*
    ([www.cdc.gov/ncidod/sars/clinicalguidance.htm](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).

> [Enhanced Activities]{.underline}

-   If epidemiologic links between some local SARS cases cannot be
    readily established (i.e., the source of infection is unclear),
    consider SARS-CoV disease in the differential diagnosis and
    management of all patients with fever or lower respiratory symptoms,
    regardless of whether the patient has SARS risk factors (see
    Supplement C and Supplement I for guidance on triage and infection
    control).

> ***Hospital-based surveillance***
>
> This section includes recommendations for SARS surveillance in
> healthcare facilities. For detailed recommendations on screening and
> triage, access controls, and infection control measures in healthcare
> settings, see Supplement C and Supplement I.
>
> *Healthcare facility with no cases of SARS*
>
> [Basic Activities]{.underline}

-   Continue to implement case detection and reporting efforts as
    detailed above (absence of SARS-C0V transmission in the world) to
    identify potential SARS patients for whom an epidemiologic link is
    unknown.

-   Screen all patients presenting to emergency rooms or hospital
    clinics with a fever or respiratory symptoms for SARS risk factors.

-   Infection control personnel, occupational health officials, and
    providers should be alert for clusters of pneumonia requiring
    hospitalization among healthcare workers. Any clusters with illness
    with onset within the same 10-day period should be reported to local
    or state health officials.

-   Report any potential SARS cases to the state or local health
    department according to their instructions.

[Enhanced Activities]{.underline}

-   If SARS-CoV transmission is occurring in the surrounding community,
    screen all visitors upon entry to the facility for fever or lower
    respiratory symptoms. Screen symptomatic persons for SARS risk
    factors. Patients with risk factors should be isolated and evaluated
    according to the algorithm in *Clinical Guidance on the
    Identification and Evaluation of Possible SARS-CoV Disease among
    Persons Presenting with Community-Acquired Illness*
    ([[www.cdc.gov/ncidod/sars/clinicalguidance.htm]{.underline}](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).

> *Healthcare facility with a few SARS cases, but no evidence of
> nosocomial transmission*
>
> [Basic Activities]{.underline}

-   Continue all recommended surveillance plans outlined in the previous
    section.

> Implement daily monitoring of all healthcare workers caring for SARS
> patients. If a healthcare worker caring for SARS patients develops
> fever or lower respiratory symptoms or two or more early symptoms of
> SARS-CoV disease (chills, rigors, myalgia, headache, diarrhea, sore
> throat, rhinorrhea), notify the local health department, begin SARS
> isolation precautions, and initiate a clinical evaluation as outlined
> in the algorithm in *Clinical Guidance on the Identification and
> Evaluation of Possible SARS-CoV Disease among Persons Presenting with
> Community-Acquired Illness*
> ([[www.cdc.gov/ncidod/sars/clinicalguidance.htm]{.underline}](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).
> The more common early symptoms of SARS-CoV disease include chills,
> rigors, myalgia, and headache; in some patients, myalgia and headache
> may precede the onset of fever by 12-24 hours. However, diarrhea, sore
> throat, and rhinorrhea may also be early symptoms of SARS-CoV disease.

[Enhanced Activities]{.underline}

-   Screen all patients, visitors, and employees upon entry to the
    facility for fever or lower respiratory symptoms. Screen symptomatic
    persons for SARS risk factors. Patients with risk factors should be
    isolated and evaluated for both alternative respiratory illnesses
    and SARS-CoV disease
    ([[www.cdc.gov/ncidod/sars/clinicalguidance.htm]{.underline}](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).

> Healthcare facility with a larger number of SARS cases OR nosocomial
> transmission with all cases linked to a clearly identified source
>
> [Activities]{.underline}

-   Continue all recommended surveillance plans outlined in the previous
    section.

-   Monitor *all* healthcare workers daily for fever or lower
    respiratory symptoms. If a healthcare worker has fever or lower
    respiratory symptoms, begin SARS isolation precautions (Supplement
    I), obtain a chest x-ray, and initiate a preliminary clinical
    evaluation
    ([[www.cdc.gov/ncidod/sars/clinicalguidance.htm]{.underline}](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).
    Continue to screen all healthcare workers caring for SARS patients
    using the expanded clinical criteria. In addition to fever or lower
    respiratory symptoms, screen for the presence of any of the
    following: chills, rigors, myalgia, headache, diarrhea, sore throat,
    rhinorrhea.

-   Begin inpatient surveillance. Monitor patients daily for new or
    worsening respiratory symptoms. If found, investigate the patient
    for exposure to known or suspected SARS patients. If there is
    evidence of exposure, isolate the patient and test for alternative
    respiratory illnesses and SARS-CoV disease
    ([[www.cdc.gov/ncidod/sars/clinicalguidance.htm]{.underline}](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).

> *Healthcare facility with cases attributed to nosocomial transmission
> with no clearly identified source*
>
> [Activities]{.underline}

-   Continue all recommended surveillance plans outlined in the previous
    section.

-   Expand inpatient surveillance. Test any patient with new or
    worsening fever or respiratory symptoms for SARS-CoV regardless of
    whether the patient has an epidemiologic link to a SARS case
    ([[www.cdc.gov/ncidod/sars/clinicalguidance.htm]{.underline}](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).

-   Consider surveillance for illness and absenteeism among healthcare
    workers.

> **Activities: State and local health departments**

-   Continue activities outlined above, as appropriate.

-   Identify, evaluate, and monitor exposed contacts of SARS cases to
    identify previously unrecognized or secondary cases, as outlined
    below.

-   Disseminate modified surveillance and patient screening guidelines
    to providers through the state/local Health Alert Network.

-   Facilitate reporting from hospitals. If necessary, consider placing
    surveillance staff in hospitals with multiple SARS admissions.

-   Review reports daily of persons reported from hospitals/providers
    to: 1) evaluate the level of risk for SARS, 2) ensure adequate
    testing to rule out SARS-CoV, 3) identify new clusters that might
    require special attention, 4) identify contacts and ensure that they
    are evaluated and monitored (as outlined below), and 5) monitor
    trends.

-   Once person-to-person SARS-CoV transmission is documented anywhere
    in the world, report to CDC any person who meets the case definition
    for a probable case of SARS-CoV disease or a confirmed case of
    SARS-CoV disease, as defined by CSTE (see Appendix B1).

-   Immediately report to CDC any positive SARS-CoV test results.

-   Following discussions between CDC and CSTE, CDC may also require
    reporting of other potential SARS-CoV cases (e.g., SARS reports
    under investigation \[SARS RUIs\]) as needed to meet national
    surveillance objectives. Updated national reporting requirements
    will be circulated to state and local health departments and posted
    on CDC's SARS website ([www.cdc.gov/sars](http://www.cdc.gov/sars))
    as indicated.

> **Activities: CDC**

-   Continue activities outlined above, as appropriate.

-   Ensure that all states have systems to identify and monitor
    potential SARS cases and contacts.

-   Ensure that states and hospitals have adequate guidance to implement
    effective surveillance and containment measures.

-   As SARS activity evolves, work with CSTE to determine what
    surveillance information and related reporting mechanisms are needed
    to meet national surveillance objectives.

-   Monitor the level of activity of SARS-CoV disease nationwide to:

    -   Monitor the effectiveness of U.S. efforts to diagnose and
        contain SARS-CoV

    -   Provide timely feedback to states in the form of data and other
        information

    -   Mobilize additional resources, and arrange surge capacity as
        needed

    -   Report activity to WHO to assist with global surveillance and
        control

-   Oversee surveillance at ports of entry to aid in the identification
    of possible imported SARS-related illnesses, as outlined in
    Supplement E.

-   Facilitate coordinated surveillance and related activities in
    settings that may not be under state/local jurisdiction (e.g.,
    military bases).

-   Provide guidance regarding possible laboratory-acquired SARS-CoV
    infections, as outlined in Supplement F.

For more information, visit
[www.cdc.gov/ncidod/sars](http://www.cdc.gov/ncidod/sars/) or call the
CDC public response hotline\
at (888) 246-2675 (English), (888) 246-2857 (Español), or (866) 874-2646
(TTY)

[^1]: Close contact: A person who has cared for or lived with a person
    with SARS-CoV disease or had a high likelihood of direct contact
    with respiratory secretions and/or body fluids of a person with
    SARS-CoV disease. Examples of close contact include kissing or
    hugging, sharing eating or drinking utensils, talking within 3 feet,
    and direct touching. Close contact does not include activities such
    as walking by a person or briefly sitting across a waiting room or
    office.

[^2]: Persons who work in laboratories that contain live SARS-CoV should
    report any febrile and/or respiratory illnesses to the supervisor.
    They should be evaluated for possible exposures, and their clinical
    features and course of illness should be closely monitored. If
    laboratory workers with fever and/or respiratory illness are found
    to have an exposure to SARS-CoV, they should be managed according to
    the recommendations in Supplement F, Appendix F6.