CDC0508.03

Hello, I\'m Dr. Julie Geberding, director of the Centers for Disease
Control and Prevention. Thank you for joining us today for a clinical
update on severe acute respiratory syndrome. Front line physicians and
local and state health officials have been stellar in their response to
this outbreak. Your hard work is paying off. We are managing to contain
this outbreak right now. But we must, of course, remain vigilant. Our
greatest concern continues to be those who have been their directly
affected by this illness, the infected individuals, their families and
loved ones. We extend our heart-felt sympathy to these people, and at
the same time express our resolve to continue to seek answers to this
global epidemic. Like many new infectious diseases, the outbreak of sars
has been followed by an outbreak of fear. This fear is initiating
discrimination against those whom the public perceives to be most at
risk for contracting and transmitting the disease. We must all emphasize
that the culprit here is the virus, not communities or racial groups. We
are cautiously optimistic that sars can be contained. Our strategy
focuses on early detection and isolation of suspect cases and active
monitoring of exposed persons during the ten-day incubation period. cdc
continues to work in collaboration with the World Health Organization as
well as with other international colleagues to investigate all aspects
of the sars outbreak. We have come a long way in a very short time, but
we realize that there is still a tremendous amount to learn about this
new virus. Please refer to the WHO and cdc web sites for the most
current information on sars. I thank you for joining us today and for
the work you do everyday in the fight against this global health
problem.

Hello, everyone. I\'m Kysa Daniels. Welcome to \"Increasing Clinician
Preparedness For Severe Acute Respiratory Syndrome \-- sars\". We are
coming to you live from the Centers For Disease Control and Prevention
in Atlanta, Georgia. The goal of today\'s program is to provide the
clinical and public health communities updated information regarding
sars and guidance to increase clinical preparedness. By the end of this
program, we want you to be able to do a few things.

1.  Describe key strategies for early clinical recognition and
    management of patients with sars.

2.  Determine appropriate clinical and laboratory diagnostic tests for
    sars.

3.  Articulate patient education messages regarding infection prevention
    and control.

If you are having technical trouble receiving our signal, you can call
us here at cdc at 800-728-8232. Continuing education credit will be
offered for a variety of professions, based on one hour of instruction.
A certificate of credit or a certificate of attendance will be awarded
to participants who complete the evaluation. For the purposes of
disclosure, today\'s speakers have stated that they have no financial
interest or other relationships with any commercial products or
services. Coming up in just a few minutes, Dr. John Jernigan will
mention an off label use of a product. He will mention that some
clinicians have used ribavirin in an off-label fashion. But he will not
advocate its use in this way. No other presenters will discuss unlabeled
use of commercial products or products for investigational use. I will
give you more registration information later in the broadcast. During
the day of the broadcast, May 8th, 2003, questions can be submitted via
telephone at 800-793-8598 or tty at 800-815-8152 or you can fax at
800-553-6323. We want to get a jump start and introduce our panel. Dr.
Dean Erdman is with us today, Linda Chiarello, Dr. John Jernigan, and
Dr. James Le Duc. I want to thank all of you for joining us today.

Our first speaker is Dr. John Jernigan. Dr. Jernigan is an infectious
disease specialist and co-leader for the sars clinical And Infection
Control Team at cdc. Dr. Jernigan will describe sars symptoms and
clinical findings, radiographic features of the disease, and clinical
outcomes. He also will describe the status of sars diagnosis and current
information on sars transmission. Welcome.

Thank you, Kysa. Can I have the first graphic, please? I\'d like to
begin by giving you an idea of how \-- what the clinical presentation of
severe acute respiratory syndrome, or sars, is. The best information we
have, we believe that the incubation period most commonly falls between
two and ten days. In general, the illness begins not as a respiratory
disease, but as a disease characterized by fever, chills and rigors,
accompanied by headaches, myalgias, and often malaise. We\'ve heard from
some of our international partners that the headache, myalgias, and
malaise actually may begin a little bit before the fever, as much as 24
to 48 hours before onset of fever. After that, respiratory symptoms
don\'t begin until approximately three to seven days after symptom
onset. And those symptoms are most commonly dyspnea and dry cough. This
graphic shows the most common symptoms reported by patients with sars.
You can see, fever seems to be present in nearly all patients. Cough and
dyspnea are very common. Cough is usually dry and unproductive. Chills
and rigor have been very frequent findings amongst all the reporting
sites as has myalgias and headache. Interestingly, diarrhea has been
recorded in a significant proportion of patients, although this has
varied by site, as low as 10-15 % in some reporting centers and as high
as two-thirds of the patients in others.

These are data from patients in the United States who have had
definitive diagnostic testing for the sars-associated coronavirus. All
the patients represented in this slide have met the case definition for
either suspect or probable sars based upon clinical and epidemiologic
criteria. The column on the left represents those who had laboratory
evidence confirming the infection with sars, and the column on the right
represents those who have had sars-associated coronavirus infection
ruled out by various lab techniques, including the absence of serologic
response after at least 21 days following the onset of symptoms.
Overall, the two groups are fairly similar. I will point out that the
symptom of dyspnea was present in all of the coronavirus-positive
patients. And this was higher than in the coronavirus-negative group, a
difference which approached a statistically different difference. In
addition, diarrhea was disproportionately represented among the
coronavirus-positive group. Of note, upper respiratory tract symptoms
were only present in one of our six patients and seemed to be present in
the lower proportion compared to those that were coronavirus negative.

These are some other clinical findings that are commonly seen in
patients with sars. On physical examination, it\'s common to have rales
and rhonchi on pulmonary exam. And hypoxia, defined by an oxygen
saturation of less than 95% on room air, has been very commonly seen as
well. Laboratory findings include, usually, a normal white blood cell
count. It's only rarely elevated. In a small proportion of patients the
white blood cell count is actually low. Lymphopenia seems to be very
common, present in over half of the patients. Low platelets are seen in
a small minority of patients as are increases in

transaminases, increase in LDH and CPK. Actually, increases in the
lactate dehydrogenase are seen in a large majority of patients. Again,
these are data with those same clinical laboratory findings and physical
findings on our group of patients who have been tested for coronavirus,
those who have had documented infection and those who had coronavirus
infection ruled out. As you can see, having rales or rhonci on
examination, being hypoxic, having pulmonary infiltrates has been
statistically associated with coronavirus infection. From a laboratory
point of view, these numbers are small. We haven\'t demonstrated any
statistically significant differences; however, leukopenia, lymphopenia,
low platelets, and increased transaminases may be associated with
coronavirus infection.

The radiographic features of sars include a predominance of patients who
do have pulmonary infiltrates. Ultimately, we think at least 80% of
cases will go on to develop pulmonary infiltrates at some point in their
illness although not necessarily on admission. As many as 25% to 40% of
patients may present actually with normal chest x-rays and then progress
to develop infiltrates. The characteristic of the infiltrates is as
follows. Initially, the infiltrates appear to be focal in most patients.
They\'re most often described as interstitial and most infiltrates will
progress to involve multiple lobes and actually to involve bilateral
lung fields. To give just a few examples of x-rays, this is an x-ray of
a patient with sars that was published in the New England Journal of
Medicine several weeks ago. You can see an ill-defined left lower lobe
infiltrate that progressed over time to involve both lower lobes
bilaterally, and rather patchy and ill-defined in nature. There seems to
be a predisposition to the lower lobes as this spreads. This is a
different case that presented with bilateral involvement involving
multiple lobes and patchy interstitial-looking infiltrate that over a
very short period of time, over 48 hours, progressed to involve an
ARDS-looking picture.

Regarding the clinical outcome of patients with sars, these are data
from various reporting centers, including three different centers in
Hong Kong, who published case histories of patients, that give the
proportion of those patients with sars who progressed to respiratory
failure as defined by requiring mechanical ventilation. As you can see,
the majority of the sites are reporting between 10% and 20% of patients
who actually do progress to respiratory failure. One center in Hong Kong
reported that 38% of their patients required mechanical ventilation.

This table shows data on the case fatality rate that were taken off the
World Health Organization web site. As you can see, centers in Canada
and Singapore and Hong Kong represented case-reported case fatality
rates between 10% and 15%. We\'ve had no deaths to date in the United
States. These numbers could represent an underestimate. The outcome for
some of these patients is not yet known. Recent estimates from data
collected in Hong Kong suggest that the case fatality rate may be
somewhat higher, as high as 20%, and may vary widely, depending on the
age group, with those greater than 65 years of age potentially having
case fatality rates of greater than 40% and those of younger age groups
having much lower fatality rates. These data do however illustrate that
sars can be a very serious illness.

Several of the centers have tried to identify clinical features that are
associated with severe disease. Most of the centers have seen an
association with older age, and more severe outcome, as I\'ve just
mentioned. In addition, underlying illness seems to be associated with
more severe disease. Some have suggested that the lactate dehydrogenase
levels may be associated with more severe illness, and severe
lymphopenia may also be associated.

One critical question that remains unanswered is precisely how long is
the period of communicability. We don't yet know the answer to that
question, but we do have data on viral shedding in Hong Kong that were
made available on the World Health Organization web site. These are data
from 20 patients who initially had evidence of sars associated
coronavirus by RT-PCR in their nasopharyngeal aspirates. And they
followed their nasopharyngeal aspirates, their stool, and their urine
over time to see how frequently the virus could be identified by pcr. As
you can see, as far out as 21 days significant proportions of patients
are still shedding, at least as identified by RT-PCR, the
SARS-associated coronavirus in all those body fluids. It should be noted
that many of these patients were receiving corticosteroids, and this
could influence the degree of shedding. And the implications that these
may have on the duration of communicability still remain unknown.

With regard to transmission, we believe that the epidemiology suggests
that the major modes of transmission are large droplet aerosolization
and contact, either direct by direct contact with the patient, or
perhaps by indirect contact with fomites. There is evidence that the
virus can persist for some period of time after drying on inanimate
surfaces. Airborne transmission cannot be ruled out in all cases, and in
fact, there\'s concern that there may be clusters of infections among
health care workers who have been involved in aerosol-generating
procedures. And in these settings in particular, we\'re concerned that
airborne transmission could take place. There\'s been some suggestion,
especially in light of the data on shedding the virus in the stool, that
fecal/oral transmission can play a role. But we need more epidemiologic
investigations to explore this further. I should also note that
transmission efficiency may very widely from individual to individual.

This graphic was shared by the Singapore Ministry of Health and is
published in the mmwr. It shows probable cases of sars reported by
source of infection in Singapore. Each of the red dots represents a
probable case of sars, and the dots that are connected by arrows
represent transmission from one patient to another. What this
illustrates is that there are five particular patients that were
associated with large numbers of secondary transmissions, while many of
the others, most of the others, were not associated with any, or with
very few secondary transmissions. In all, 81% of the individuals in this
diagram were associated with no secondary transmissions, and only 3%
transmitted the illness to at least five other people. We don\'t
understand this phenomena and what makes a person more likely to be
involved with large numbers of secondary transmissions. It could involve
host factors, pathogen factors, environmental factors, or some
combination of the three.

With regard to diagnosing patients who may be presenting with possible
sars, i think it\'s first \-- it\'s important\-- to remember to consider
other potential etiologies. We recommend that the diagnostic workup
should include a chest radiograph; blood and sputum cultures; pulse
oximetry measured on room air; testing for other viral pathogens when
appropriate, for example, influenza; and consideration should be given
to testing urinary antigens for legionallis species, and streptococcus
pneumoniae. It\'s important to remember to save clinical specimens,
including respiratory blood and serum specimens. Remember to save an
acute sera, and make plans for collecting a convalescent serum at least
21 days after onset of symptoms so antibody testing for the
SARS-associated coronavirus can be performed. Your local and state
health departments can assist you in how to collect the specimens and
where to send the specimens for further testing.

With regard to treatment of patients with sars, unfortunately we have a
lot yet to learn. The most effective therapeutic options still remain
unknown. It may be particularly important to optimize supportive care,
and in particular, those patients who require intensive care unit care.
It\'s important to remember to treat for other potential causes of
community acquired pneumonia of unknown etiology, and include agents
that cover typical and atypical course of pathogens at least until a
definitive diagnosis is made.

Potential therapies that require further investigation include those on
the slide. Ribavirin with or without corticosteroids have been used
around the world. There are anecdotal reports of success; however, we
think that these data are difficult to interpret and that we need more
information from controlled clinical trials to determine the benefit of
this particular therapy. Ribavirin has been tested *in vitro* in several
laboratories and has been not found to have any demonstrable biological
activity against this particular virus. However, it\'s possible that
there may be other nonvirologic effects of ribavirin, including
potential immunomodulatory effects that could conceivably have benefit.
This again needs to be studied in controlled trials. We\'re working
collaboratively with the NIH and others to test large numbers of
antiviral agents to try to come up with compounds that may be of
benefit.

There is an existing hypothesis that some of the pathogenesis may
involve an immune response to the infection, and therefore
immunomodulatory agents have been proposed as possibly being beneficial.
Corticosteroids have been used widely, interferons have been given
consideration, and there are others that are under consideration. For
the moment, again to summarize, we don\'t know the most effective
therapeutic options for this infection.

With regard to infection control, we think that early recognition and
isolation of the patient is key. Clinicians should maintain heightened
suspicion for patients who might present to their hospitals or offices
who might be at risk for sars, and triage procedures should be adjusted
accordingly to be able to pick up these people early and isolate them
early on after their presentation. It\'s important to remember that
transmission may occur during the very earliest symptomatic phases,
potentially before both fever and respiratory symptoms develop, that is,
before they actually might meet the case definition for sars.

THE BASICS OF INFECTION CONTROL INCLUDE CLEAN HAND HYGIENE, contact
precautions, EYE PROTECTION, AND ENVIRONMENTAL CLEANING AS WELL AS
protection against AIRBORNE PRECAUTIONS. I THINK IT\'S IMPORTANT TO
REMEMBER THAT THIS IS AN AREA WHERE OUR KNOWLEDGE BASE IS RAPIDLY
EXPANDING, AND WE\'LL DO OUR BEST TO KEEP CLINICIANS INFORMED AS WE GET
MORE INFORMATION.

\>\> Kysa: DR. JERNIGAN, WE certainly APPRECIATE YOUR EXPERTISE. THANK
YOU.

LET\'S TURN OUR ATTENTION TO DR. DEAN ERDMAN. DEAN ERDMAN IS A DOCTOR OF
PUBLIC HEALTH AND ACTING CHIEF OF THE RESPIRATORY AND VIRAL DISEASE
SECTION AT CDC. DR. ERDMAN WILL DISCUSS THE STATUS OF LABORATORY
DIAGNOSIS OF SARS INFECTION, INCLUDING CHARACTERISTICS OF THE SARS
CORONAVIRUS, THE TYPE AND TIMING OF SPECIMEN COLLECTION, AND TYPES OF
ASSAYS. WELCOME.

\>\> THANK YOU, KYSA. MAY I HAVE THE FIRST SLIDE, PLEASE? BEFORE
BEGINNING MY PRESENTATION ON THE LABORATORY DIAGNOSIS OF SARS, THERE IS
ONE KEY POINT

OF WHICH WE NEED TO REMIND OURSELVES. SARS IS EXPLICITLY A CLINICAL

AND EPIDEMIOLOGIC diagnosis. Therefore, it is likely that MANY SARS
CASES AS DEFINED ARE NOT ACTUALLY INFECTED WITH THE SARS CORONAVIRUS,
AND THIS has VERY IMPORTANT IMPLICATIONS FOR THE INTERPRETATION OF
LABORATORY RESULTS.

NOW, TO ESTABLISH RELIABLE LABORATORY EVIDENCE OF SARS INFECTIONS, WE
NEED TO CONSIDER THREE IMPORTANT ISSUES: 1. THE TYPE OF SPECIMEN TO
COLLECT,

2\. THE TIMING OF SPECIMEN COLLECTION, AND 3. THE SELECTION OF

laboratory ASSAY TO DETECT INFECTION. IN GENERAL, MOST OF THESE ISSUES

WERE ADDRESSED IN THE WEEKS FOLLOWING THE RECOGNITION OF THE

OUTBREAK. HOWEVER, THERE ARE STILL MANY SPECIFIC DETAILS FOR WHICH WE DO

NOT AS YET HAVE AN ANSWER. THERE IS NOW A STRONG ASSOCIATION BETWEEN THE
NEWLY

IDENTIFIED CORONAVIRUS AND SARS BASED ON MULTIPLE LINES OF EVIDENCE.

BOTH BIOLOGICAL AND SEROLOGICAL identification of the novel CORONAVIRUS
HAVE BEEN MADE IN SARS CASES AT CDC AND in MULTIPLE LABORATORIES AROUND
THE

WORLD. IN CONTRAST, NON-SARS PATIENTS HAVE NO SEROLOGIC EVIDENCE of past
infection with this virus, AS

DEMONSTRATED IN SEPARATE LABORATORIES, BOTH AT CDC AND IN

HONG KONG.

THE VIRUS HAS BEEN IDENTIFIED BY CULTURE, IN PCR, FROM LOWER

RESPIRATORY TRACT SPECIMENS, and LUNG, LINKING IT MORE DIRECTLY

TO THE SITE OF PATHOLOGY. ALSO, GENETIC SEQUENCES FROM

MULTIPLE VIRUS ISOLATES FROM DIFFERENT GEOGRAPHIC LOCATIONS

ARE ESSENTIALLY IDENTICAL, SUGGESTING A POINT SOURCE OUTBREAK. And
RECENT STUDIES IN THE NETHERLANDS have demonstrated that a similar
clinical presentation can be induced in nonhuman primates following
infection with the SARS coronavirus alone. HOWEVER, QUESTIONS REMAIN.
DOES PATHOLOGY RESULT IN DIRECT

VIRUS INFECTION OF TISSUE OR FROM SUBSEQUENT IMMUNE RESPONSE? AND WHAT
IS THE TRUE RATE Of POSITIVITY IN SARS CASES?

THE ETIOLOGIC AGENT OF SARS IS SHOWN IN THIS ELECTROnMICROGRAPH.

NOTE THE CHARACTERISTIC FRINGE OF PROTEINS ON THE VIRUS SURFACE,
referred to as peptoburrs, WHICH ARE VERY CHARACTERISTIC OF THE
CORONAVIRUSES.

CORONAVIRUSES RESIDE withIN THE ORDER OF THE VERALES, Family
coronaviridae.

WITHIN THIS FAMILY, THE GENUS coronovirus has BEEN classically
subdivided INTO THREE MAJOR antigenic GROUPS, ONE, TWO, AND THREE. ALL
OF THE KNOWN HUMAN AND

ANIMAL CORONAVIRUSES CAN BE CLASSIFIED WITHIN THESE THREE GROUPS. THE
TWO HUMAN CORONAVIRUSES, 229-E, AND OC-43, RESIDE IN GROUPS 1 AND 2
RESPECTIVELY. THE KNOWN HUMAN CORONAVIRUSES HAVE BEEN LINKED PRIMARILY
TO MILD UPPER RESPIRATORY ILLNESSES and like RHINOVIRUSES, are a major
cause of THE COMMON COLD.

THE animal CORONAVIRUSES IN CONTRAST have representatives IN ALL THREE

GROUPS, AND THE SPECTRUM OF DISEASE CAUSED BY THE ANIMAL

CORONAVIRUSES IS quite BROAD, both in terms of major organ systems
affected and SEVERITY OF DISEASE.

THE COMPLETE GENOME of the SARS coronavirus HAS NOW BEEN SEQUENCED both
at CDC and MULTIPLE other LABORATORIES.

THE GENETIC ORGANIZATION OF THE SARS

CORONAVIRUS IS illustrated IN

THIS SLIDE, SHOWING THE

PREDICTED OPEN READING FRAMES,

OR GENES, AND messenger RNA TRANSCRIPTS.

THIS SEQUENCE DATA HELPED US TO

DETERMINE, ONE, THAT THE SARS

CORONAVIRUS IS ENTIRELY NEW, NOT

a recombinant or PREVIOUSLY KNOWN VIRUS, AND

TWO, IT HELPS US DEVELOP

DIAGNOSTIC ASSAYS THAT CAN

DISTINGUISH SARS FROM ALL other

KNOWN CORONAVIRUSES.

NOW, SUCCESSFUL LABORATORY

DIAGNOSIS OF SARS INFECTION

REQUIRES A THOROUGH

UNDERSTANDING OF THE TYPE AND

TIMING OF SPECIMEN COLLECTION

AND THE TYPE OF ASSAYS TO APPLY WITH A FULL UNDERSTANDING OF THE

STRENGTH AND WEAKNESSES OF THOSE

ASSAYS. AS MORE CLINICAL AND

EPIDEMIOLOGICAL DATA HAVE BECOME

AVAILABLE, WE HAVE BEEN ABLE TO

REFINE OUR CHOICE OF SPECIMENS

TO COLLECT. ASSAYS INTRODUCED AT THE

BEGINNING OF THE OUTBREAK ARE

RAPIDLY BEING REPLACED WITH

ASSAYS WITH IMPROVED SENSITIVITY

AND SPECIFICITY. HOWEVER, THE BOTTOM LINE IS THAT

AT THIS EARLY STAGE OF THE

OUTBREAK, WE NEED MORE

INFORMATION.

NOW, LABORATORY ASSAYS FOR THE

SARS CORONAVIRUS ARE BASED

EITHER ON detection OF THE VIRUS

OR VIRUS PRODUCTS, OR detection

OF AN ANTIBODY RESPONSE to viral infection.

VIRUS ISOLATION in virocells and

ELECTROnMICROSCOPy PLAYED A

CRUCIAL ROLE IN THE EARLY

IDENTIFICATION OF THE SARS

CORONAVIRUS. And THE CAPACITY TO GROW THE

VIRUS to high titer IN THESE CELLS ALLOWED

RAPID DEVELOPMENT of

SEROLOGICAL ASSAYS using whole virus antigen preparations.

However, both electron microscopy and CULTURE LACK SENSITIVITY FOR

ROUTINE DIAGNOSIS, AND CULTURE

POSES A PARTICULAR HAZARD

OUTSIDE BIOSAFETY LEVEL 3

FACILITIES. DETECTION OF VIRAL ANTIGENS IS A

POSSIBILITY AND USEFUL FOR immunohistochemistry

WITH TISSUES.

BUT WE SUSPECT THAT ASSAYS LIKE

IFA AND ELISA for antigen detection IN RESPIRATORY

SECRETIONS AND OTHER SPECIMENS

WOULD BE LESS SENSITIVE THAN

DESIRABLE FOR ROUTINE USE.

THE KEY ASSAY FOR US AND OTHERS

HAS BEEN PCR. OUR PCR ASSAYS HAVE EVOLVED FROM

A SINGLE genome TARGET USING MORE

CONVENTIONAL AMPLIFICATION and product detection

METHODS TO REALTIME Taqman PCR FORMAT USING

MULTIPLE genome TARGETS. WE ARE ALSO DEVELOPING MORE

EXTENSIVE EXPERIENCE WITH THIS

ASSAY OVER A WIDE RANGE OF

CLINICAL SAMPLES.

CDC HAS ALSO developed SEROLOGICAL ASSAYS based on IFA and Elisa THAT
ARE

BEING USED FOR ROUTINE ANTIBODY

SCREENING AS WELL AS PLAQUE

NEUTRALIZATION ASSAYS USED FOR

SPECIFIC STUDIES.

OUR REALTIME [TAqMAN]{.underline} RT-PCR assay IS THE CORE

TEST on WHICH WE currently RELY FOR SPECIMEN

SCREENING. MOST OF YOU, I AM SURE, ARE

FAMILIAR WITH THIS METHODOLOGY,

BUT BRIEFLY, WITH TAqMAN, ONE

PERFORMS a CONVENTIONAL PCR

AMPLIFICATION IN THE PRESENCE OF

A PROBE THAT IS SPECIFIC to THE

AMPLIFIED PRODUCT. AS AMPLIFICATION PROCEEDS, AND

THE PRODUCT GENERATED, THE PROBE

hybridizes TO THE PRODUCT AND is

IMMEDIATELY DEGRADED by the advancing Taq polymerase, WHICH

POSSESSES ENDONUCLEase

ACTIVITY. SPECIALIZED LABELS ATTACHED TO

THE PROBE RELEASE LIGHT WHEN THE

PROBE IS DEGRADED. LIGHT EMISSION INCREASES

PROPORTIONALLY WITH PRODUCT

AMPLIFICATION. WITH A SPECIALLY EQUIPPED

THERMOCYCLER, THIS light emission CAN BE

MEASURED DURING THE

AMPLIFICATION REACTION, HENCE,

REALTIME PCR.

THEse DATA THAT YOU SEE ON the

SLIDE ARE ACTUAL RESULTS

OBTAINED WITH OUR SARS REALTIME

PCR ASSAY, SHOWING POSITIVE

REACTIONS OBTAINED IN SEVERAL SAMPLES. FOR EACH SPECIMEN, WE AMPLIFY

THREE DIFFERENT TARGETS IN TWO SEPARATE GENES, AND INCLUDE

HOUSEKEEPING GENE control to ensure RNA INTEGRITY.

ALTHOUGH OUR REALTIME PCR HAS BEEN EXTENSIVELY EVALUATED FOR

SENSITIVITY AND SPECIFICITY USING RNA EXTRACTS FROM THE SARS

CORONAVIRUS AND OTHER RESPIRATORY PATHOGENS, WE ARE STILL GATHERING DATA
TO ASSESS ITS PERFORMANCE WITH CLINICAL SAMPLES. NEVERTHELESS, WE CAN
DRAW SOME

PRELIMINARY CONCLUSIONS FROM DATA THAT WE HAVE OBTAINED THUS FAR.
RESPIRATORY SPECIMENS ARE STILL THE SPECIMENS OF CHOICE FOR DETECTION OF
SARS CORONAVIRUS by PCR. UPPER RESPIRATORY TRACT SPECIMENS ARE POSITIVE
IN APPROXIMATELY 50% OF ACUTE phase SPECIMENS FROM TRUE SARS-POSITIVE
CASES. AMONG THE RANGE OF POSSIBLE

RESPIRATORY SPECIMENS, IT APPEARS THAT SPUTUM and BALs MAY OFFER

HIGHER RATES OF POSITIVITY. Data from other laboratories suggest that
STOOL MAY ALSO BE A PROMISING

SPECIMEN, WITH REPORTS SUGGESTING THAT STOOL SPECIMENS OFFER HIGHER
SENSITIVITIES LATER IN ILLNESS. THERE STILL REMAINS A QUESTION

REGARDING THE VALUE OF OTHER CLINICAL SPECIMENS, HOWEVER.

NOW, ONCE YOU OBTAIN YOUR PCR RESULT, HOW DO YOU INTERPRET IT?

A NEGATIVE RESULT DOES NOT RULE OUT SARS CORONAVIRUS INFECTION,

WHICH MAY BE BELOW THE LEVEL OF DETECTION DUE TO INADEQUATE SPECIMEN
COLLECTION OR PCR INHIBITION. And a POSITIVE PCR RESULT DOES NOT
GUARANTEE INFECTION as contamination of the assay with the PCR product
can BE DIFFICULT TO

DISTINGUISH FROM A TRUE POSITIVE RESULT. BUT ONE TRUTH REMAINS, TO BE

USEFUL, PCR MUST BE APPLIED DURING THE ACUTE PHASE OF ILLNESS.

AS MENTIONED EARLIER, CDC AND OTHERS HAVE DEVEloped SEROLOGICAL TESTS
BASED ON

IMMUNOFLUORESCENCE and ELISA FOR DETECTION OF SARS CORONAVIRUS-specific
IGG ANTIBODIES. THESE ASSAYS REPRESENT THE MOST DEFINITIVE TESTS FOR
SARS

DIAGNOSIS ALTHOUGH RESULTS ARE UNAVOIDABLY DELAYED.

ASSAY DESIGN FOLLOWS THE CONVENTIONAL INDIRECT ASSAY

FORMAT, AS ILLUSTRATED.

A DETERGENT EXTRACT OF CULTURED

VIRAL LYSATE IS coated onto GLASS SLIDES or microtiter plates.

THIS IS FOLLOWED BY a DILUTION

OF THE PATIENT\'S SERUM.

SPECIFIC IGG antibodies present in the serum BIND TO THE viral ANTIGEN

WHICH are in TURN DETECTED WITH

Antihuman IGG CONJUGATE, AND THE

RESULTING flouresence are COLOR MEASURED.

THE DELAY IN PROVIDING WIDER

DISTRIBUTION OF THIS ASSAY HAS

BEEN THE LACK OF POSITIVE

CONTROL SERA. WE HAVE RECENTLY ACQUIRED PLASMA

UNITS FROM CONVALESCENT SARS

CASES, WHICH WILL BE USED TO MAKE

A POSITIVE CONTROL IN QUANTITY.

[]{.mark}

IN DEVELOPMENT, are recombinant PROTEINS TO

REPLACE THE WHOLE VIRUS antigen and

monoclonal antibodies for USE IN DEVELOPMENT OF

CAPTURE IGM ASSAYS THAT WILL

permit serologic DIAGNOSIS EARLIER IN THE

COURSE OF INFECTION.

AGAIN, WE ARE STILL ACQUIRING

DATA THAT WILL HELP US ASSESS

THE PERFORMANCE OF OUR SEROLOGIC TESTS.

WHAT SEEMS CLEAR IS THAT THERE

IS VERY LOW OR NO ANTIBODIES IN

PERSONS WITHOUT ACUTE SARS.

IN PERSONS WITH DEFINITIVE SARS coronavirus

INFECTION, the acute phASE

SERUM MAY HAVE DETECTABLE

ANTIBODy as early as SIX DAYS after onset of illness.

AND convalescent sera SHOULD BE POSITIVE by 21

DAYS.

INTERPRETATION OF SEROLOGICAL

TESTS IS more STRAIGHTFORWARD than for PCR.

TODAY WE CAN ASSUME FROM A

SINGLE POSITIVE SERUM SPECIMEN

THAT THE PATIENT HAS ACUTE SARS

CORONAVIRUS INFECTION.

LATER, WHEN THE NUMBER OF

POSITIVE PERSONS IN THE

POPULATION GOES UP, WE WILL NEED

TO DEMONSTRATE RISES IN IGG

ANTIBODIES OR USE IGM detection TO

DIAGNOSE ACUTE INFECTION.

And THERE WILL ALWAYS BE those

PATIENTS THAT PRODUCE A poor

IMMUNOLOGIC RESULT. IN THESE CASES AN ADDITIONAL

SPECIMEN LATER THAN 21 DAYS MAY

BE REQUIRED TO RULE OUT

INFECTION.

I HAVE ALREADY MENTIONED SOME OF

THE OTHER TESTS FOR SARS

CORONAVIRUS INFECTION, INCLUDING

TISSUE CULTURE, ISOLATION,

ELECTROMICROSCOPY, immunologic and in situ studies of tissue samples AND

ANTIGEN DETECTION assays and their relative strengths and weaknesses.

I SHOULD ALSO MENTION THAT

DURING THE LAST SEVERAL WEEKS,

WE HAVE BEEN CONTACTED BY

NUMEROUS COMPANIES OFFERING NEW

AND POTENTIALLY USEFUL ASSAYS

FOR THE SARS CORONAVIRUS,

SOME OF WHICH MAY BECOME

COMMERCIALLY AVAILABLE IN THE

NEAR FUTURE.

IN CONCLUSION, AND TO REITERATE

WHAT WAS SAID EARLIER, SARS

IS A CLINICAL AND EPIDEMIOLOGIC

DIAGNOSIS, with all that

ENTAILS FOR the interpretation of LABORATORY RESULTS.

THE LABORATORY CAN DIAGNOSE SARS

CORONAVIRUS INFECTION DURING THE

ACUTE ILLNESS BUT CANNOT RULE

OUT INFECTION UNTIL THE

CONVALESCENT PHASE WHEN SERA

CONVERSION CAN BE ASSESSED.

FINALLY, DUAL INFECTIONS WITH

OTHER VIRUSES CAN OCCUR IN

PATIENTS WITH SARS CORONAVIRUS

INFECTION; and THEREFORE, DETECTION

OF OTHER VIRUSES IN SARS CASES

MUST BE INTERPRETED WITH CARE.

THAT CONCLUDES MY PRESENTATION.

THANK YOU VERY MUCH.

\>\> AND THANK YOU, DR. ERDMAN.

NOW WE WANT TO TURN OUR

ATTENTION TO OUR NEXT PRESENTER

WHO IS MS. LINDA CHIARELLO.

MS. CHIARELLO IS AN

EPIDEMIOLOGIST AND INFECTION

CONTROL SPECIALIST

IN THE DIVISION OF HEALTHCARE

QUALITY PROMOTION AT CDC.

SHE WILL REVIEW INFECTION

CONTROL GUIDANCE FOR HEALTHCARE

PRACTITIONERS, SARS PATIENTS,

AND PERSONS EXPOSED TO SARS.

MS. CHIARELLO.

\>\> THANK YOU, KYSA.

MAY I HAVE MY FIRST GRAPHIC,

PLEASE.

DURING THE PREVIOUS

TELECONFERENCE, TWO AREAS WERE

DISCUSSED THAT ARE CRITICAL TO

AN UNDERSTANDING OF INFECTION

CONTROL. THEY ARE THE KEY OBJECTIVES FOR

PREVENTING TRANSMISSION THAT

DR. GERBERDING MENTIONED

EARLIER: EARLY detection, containment of infection, PROTECTION OF

HEALTH CARE PERSONNEL AND THE

ENVIRONMENT OF CARE, AND HAND

HYGIENE, THE CORNERSTONE OF

INFECTION PREVENTION.

ALSO DISCUSSED WERE THE

STRATEGIES OR INTERVENTIONS USED

TO MEET THESE OBJECTIVES THAT

ARE BRIEFLY OUTLINED HERE AND

ARE REFLECTED IN THE INFECTION

CONTROL GUIDANCE ON THE CDC SARS

WEB SITE.

TODAY, I WILL FOCUS ON AREAS

THAT HAVE RECENTLY BEEN

ADDRESSED AND UPDATED IN TERMS

OF INFECTION CONTROL GUIDANCE

FOR HEALTH CARE FACILITIES,

NAMELY, ISSUES AROUND

RESPIRATORY PROTECTION,

MANAGEMENT OF EXPOSED HEALTH

CARE PERSONNEL, AND

ENVIRONMENTAL CLEANING AND

DISINFECTION. I WILL ALSO TALK ABOUT THE

MANAGEMENT OF PERSONS IN THE

COMMUNITY WHO HAVE BEEN EXPOSED

TO SARS, WHICH TIES INTO THE

FIRST TWO OBJECTIVES OF EARLY

DETECTION AND CONTAINMENT OF

INFECTION.

TRANSMISSION OF SARS DURING

AEROSOL GENERATING PROCEDURES

APPEARS TO BE VERY EFFICIENT.

AS DR. JERNIGAN MENTIONED,

CLUSTERS OF INFECTION AMONG

PERSONNEL WHO WERE DIRECTLY

INVOLVED IN INTUBATION,

SUCTIONING, AND USE OF NEBULIZERS in SARS patients

HAVE BEEN DETECTED IN

TORONTO, HONG KONG, SINGAPORE, AND

HANOI. THE REASONS FOR THESE

TRANSMISSIONS ARE UNCLEAR.

ONE POSSIBILITY IS THAT PATIENT

infectivity MIGHT BE HIGHER

WITH the onset of respiratory FAILURE.

IT ALSO IS NOT KNOWN WHETHER

TRANSMISSION IS FROM A HIGH

BIOBURDEN OF RESPIRATORY

DROPLETS, HEAVY CONTAMINATION OF

THE ENVIRONMENT THROUGH AIRBORNE

SPREAD, OR A COMBINATION OF ALL

THREE.

IN SOME CASES, LACK OF

PROTECTIVE ATTIRE APPEARED TO BE

A FACTOR IN TRANSMISSION.

HOWEVER, IN OTHER EPISODES,

TRANSMISSION OCCURRED DESPITE

THE USE OF PROTECTIVE EQUIPMENT.

WHETHER THIS REPRESENTS A TRUE

FAILURE OF THE EQUIPMENT OR

IMPROPER USE OF THE EQUIPMENT IS

NOT KNOWN. THESE TRANSMISSIONS ARE AN

OBVIOUS CONCERN FOR INFECTION

CONTROL AND HAVE LED CDC TO

ISSUE RECOMMENDATIONS TO LIMIT

cough-INDUCING PROCEDURES TO

THOSE THAT ARE MEDICALLY

NECESSARY, TO AVOID USE OF

NON-INVASIVE VENTILATION, SUCH

AS C-PAP AND BI-PAP, AND TO USE

CLOSED SUCTIONING DEVICES FOR

MECHANICAL VENTILATION AND

FILTERS ON EXHALATION VALVE

PORTS. IN ADDITION, IT IS PRUDENT TO

LIMIT THE NUMBER OF PERSONNEL IN

THE ROOM TO THOSE WHO ARE

ESSENTIAL FOR PERFORMING THE

PROCEDURES. AND PERSONNEL INVOLVED IN THE

PROCEDURE SHOULD WEAR THE

APPROPRIATE PROTECTIVE EQUIPMENT

INCLUDING GOWN AND GLOVES,

SEALED EYE PROTECTION, AND BY THAT WE MEAN SOMETHING

THAT FITS OVER THE EYES SUCH AS

GOGGLES RATHER THAN A FACE

SHIELD, AND A RESPIRATORY PROTECTION

DEVICE.

CDC IS IN THE PROCESS OF

UPDATING guidance ON USE OF

RESPIRATORS FOR AEROSOL

GENERATING PROCEDURES.

UNTIL THESE RECOMMENDATIONS ARE

FINALIZED, WE WANT TO ALERT

HEALTH CARE FACILITIES ABOUT

THIS CONCERN.

ANECDOTAL INFORMATION FROM

HEALTH CARE WORKERS WHO BECAME

ILL SUGGESTED THAT THE MASK OR

RESPIRATOR THEY WERE USING DID

NOT fit WELL. THEREFORE, REASSESSMENT OF

RESPIRATOR FIT AMONG PERSONNEL

WHO MAY BE INVOLVED IN THE

INTUBATION OF SARS PATIENTS

SHOULD BE CONSIDERED. CONSIDERATION ALSO SHOULD BE

GIVEN TO USING RESPIRATORS WITH

A TIGHTER SEAL, including N-99 and N-100 devicesOR USE OF HALF

OR FULL-FACE elastomeric DEVICES, OR POWERED

AIR PURIFYING RESPIRATORS or PAPRs.

IF REUSABLE DEVICES ARE

CONSIDERED, PROCEDURES FOR

CAREFUL CLEANING AND

DISINFECTION AFTER USE ARE

NECESSARY TO PREVENT THEM FROM

BECOMING A fomite FOR

TRANSMISSION.

ANOTHER AREA WHERE CDC HAS

PROVIDED NEW INTERIM GUIDANCE

CONCERNS SURVEILLANCE FOR AND

MANAGEMENT OF SARS EXPOSURES IN

HEALTH CARE SETTINGS. SUGGESTED SURVEILLANCE

ACTIVITIES INCLUDE DEVELOPING A

LOG OF PERSONNEL WHO ENTER THE

ROOM OF PATIENTS WITH SARS.

IF THERE\'S SUBSEQUENT

TRANSMISSION, SUCH A LOG WILL

HELP FACILITIES IDENTIFY OTHER

PERSONNEL WHO MAY HAVE BEEN

EXPOSED. OTHER SURVEILLANCE ACTIVITIES

MAY INCLUDE ENCOURAGING

PERSONNEL TO REPORT UNPROTECTED

EXPOSURES AND MONITORING

EMPLOYEE ABSENTEEISM FOR

SARS-LIKE ILLNESSES SUCH AS

ATYPICAL PNEUMONIA.

AS DR. JERNIGAN MENTIONED

EARLIER, AT THIS TIME THERE IS

NO EVIDENCE FOR TRANSMISSION OF

SARS from PERSONs who have NO SYMPTOMS

OF THE DISEASE. HOWEVER, TRANSMISSION OF SARS IN

HEALTH CARE SETTINGS HAS

SOMETIMES INVOLVED HEALTH CARE

PERSONNEL WHO WORKED WITH EARLY

SYMPTOMS. IT ALSO HAS INVOLVED HEALTH CARE

PERSONNEL INVOLVED IN THE

AEROSOL GENERATING PROCEDURES,

AS I JUST DISCUSSED. THEREFORE, CDC IS RECOMMENDING

THAT ACTIVE SURVEILLANCE BE

PERFORMED DAILY ON ANY HEALTH

CARE WORKER WHO HAS AN

UNPROTECTED EXPOSURE TO A SARS

PATIENT. THIS INCLUDES MEASURING THE

WORKER\'S TEMPERATURE AND

ASSESSING FOR RESPIRATORY

SYMPTOMS BEFORE BEGINNING WORK.

IN ADDITION, CDC RECOMMENDS A

TEN-DAY EXCLUSION FROM DUTY FOR

HEALTH CARE WORKERS WHO HAVE AN

UNPROTECTED EXPOSURE DURING AN

AEROSOL GENERATING PROCEDURE,

INCLUDING AEROSOLIZED medication TREATMENTs

DIAGNOSTIC SPUTUM INDUCTION,

BRONCHOSCOPY, endotracheal intubation, AIRWAY SUCTIONing,

AND CLOSE FACIAL CONTACT DURING

A COUGHING PAROXYSM.

HEALTH CARE WORKERS WHO ARE

EXCLUDED FROM DUTIES SHOULD

LIMIT INTERACTIONS OUTSIDE THE

HOME AND SHOULD NOT GO TO WORK,

SCHOOL, CHURCH, OR OTHER PUBLIC

AREAS.

ANOTHER ISSUE WE RECENTLY

ADDRESSED CONCERNS THE LIMITED

SUPPLY OF N-95 RESPIRATORS IN

THE UNITED STATES, AND IN OTHER

COUNTRIES AND WHETHER RESPIRATORS SHOULD BE

REUSED AS IT DONE WITH

TUBERCULOSIS. THE CONCERN WITH SARS IS THE

POTENTIAL FOR CONTAMINATION

DURING PATIENT CARE EITHER FROM RESPIRATORY DROPLETS

DEPOSITED DIRECTLY ON THE FRONT

OF THE RESPIRATOR, OR FROM

TOUCHED CONTAMINATION WITH

GLOVED OR UNGLOVED HANDS IN THE

COURSE OF HANDLING THE

RESPIRATOR. FOR THIS REASON, CDC PREFERS

THAT RESPIRATORS BE DISPOSED

AFTER A SINGLE USE. HEALTH CARE FACILITIES SHOULD

TAKE STEPS TO CONSERVE LIMITED

SUPPLIES BY ASSESSING FOR

UNNECESSARY RESPIRATOR USE IN

THEIR FACILITIES.

IN THE UPDATED GUIDANCE, CDC

PRESENTS A HIERARCHY of OPTIONS

for SITUATIONS WHERE DISPOSAL

AFTER SINGLE USE IS NOT

FEASIBLE. THESE INCLUDE USING LEVEL N, P

AND R RESPIRATORS FIRST.

AND IF A CHOICE MUST BE MADE

BETWEEN REUSING RESPIRATORS OR

GOING TO USE OF A SURGICAL MASK,

REUSE IS THE PREFERRED OPTION.

PROCEDURES FOR CAREFUL HANDLING

THAT REINFORCE HAND HYGIENE

AFTER CONTACT WITH A

CONTAMINATED RESPIRATOR SHOULD

BE IN PLACE. AND THEN IF THERE IS NO RECOURSE,

THEN A SURGICAL MASK SHOULD BE

USED.

THE ENVIRONMENT AROUND A PATIENT

WITH SARS IS THOUGHT TO BE

HEAVILY CONTAMINATED AND MAY BE

A KEY FACTOR IN TRANSMISSION.

THEREFORE, CDC HAS PROVIDED NEW

GUIDANCE ON CLEANING AND

DISINFECTION FOR SARS.

THIS GUIDANCE REFLECTS THE SAME

PRINCIPLES USED FOR PREVENTING

TRANSMISSION OF OTHER INFECTIOUS

AGENTS IN THE ENVIRONMENT.

BUT IT AIMS TO REINFORCE THE

IMPORTANCE OF CLEANING AND

DISINFECTION AND TO ENCOURAGE

TRAINING OF PERSONNEL AND

MONITORING OF THIS PROCESS IN

THE ROOMS WHERE SARS PATIENTS

ARE HOUSED.

CLEANING PROCEDURES IN INPATIENT

AREAS SHOULD FOCUS ON DAILY

CLEANING OF SURFACES THAT ARE

TOUCHED FREQUENTLY, SUCH AS BED

RAILS, OVER BED TABLES, DOOR

KNOBS AND LABORATORY surfaces.

AND A MORE THOROUGH CLEANING

SHOULD BE PERFORMED AT THE TIME

OF TRANSFER OR DISCHARGE. HOWEVER, THIS DOES NOT NEED TO

INCLUDE AIR FOGGING OR ROUTINE

CLEANING OF WALLS OR CEILINGS

UNLESS THESE AREAS ARE VISIBLY

SOILED.

CDC RECOMMENDS USING AN EPA

REGISTERED HOSPITAL DETERGENT

DISINFECTANT.

SINCE IT IS LIKELY THAT MOST

HEALTH CARE FACILITIES IN THE

UNITED STATES CURRENTLY USE SUCH

AGENTS, THIS WILL NOT REQUIRE

ANY CHANGE FROM CURRENT

PROCEDURES.

I WILL NOW MOVE FROM DISCUSSING

INFECTION CONTROL IN HEALTH CARE

FACILITIES TO THE MANAGEMENT OF

EXPOSED AND SYMPTOMATIC PERSONS

WHO CONTACT CLINICIANS FOR

ADVICE.

THE INFECTION CONTROL PRINCIPLES

USED TO PREVENT TRANSMISSION OF

SARS IN THE HOME MIRROR THOSE

APPLIED IN HEALTH CARE SETTINGS.

THESE INCLUDE MONITORING EXPOSED

PERSONS IN THE HOME TO DETECT

EARLY ONSET OF SYMPTOMS,

CONTAINING THE INFECTION IN

SYMPTOMATIC INDIVIDUALS,

PROTECTING PERSONS IN THE

HOUSEHOLD FROM SUBSEQUENT

EXPOSURE, AND LIMITING

CONTAMINATION OF THE HOME

ENVIRONMENT WITH THE SARS VIRUS.

GUIDANCE ON THE MANAGEMENT OF

SARS IS BASED ON PRELIMINARY

INFORMATION ABOUT THE INCUBATION

PERIOD AND PERIOD OF infectivity AND WHETHER SOMEONE

has or MIGHT HAVE SARS or HAS ONLY BEEN

EXPOSED TO SARS.

THERE ARE THREE TIME PERIODS TO

KEEP IN MIND. THE FIRST IS TEN DAYS AFTER THE

LAST EXPOSURE TO SARS, AND

DEFINES THE END POINT FOR

MONITORING FOR INFECTION.

THIS IS BELIEVED TO BE THE

MAXIMUM INCUBATION PERIOD DURING

WHICH SYMPTOMS OF SARS SHOULD

DEVELOP FOLLOWING THE EXPOSURE.

THE SECOND IS THE 72-HOUR RULE.

THIS IS A RECOMMENDED

WAIT-AND-SEE PERIOD FOR

DETERMINING WHAT TO DO WITH AN

EXPOSED PERSON WHO HAS ONE, BUT

NOT BOTH, OF THE SYMPTOMS OF

SARS. AND THE THIRD IS THE TEN-DAY

RULE USED TO DEFINE WHEN A

PERSON WHO HAS SARS IS NO LONGER

INFECTIOUS AND CAN RETURN TO

THE COMMUNITY. AND THIS IS BASED ON RESOLUTION

OF FEVER AND IMPROVEMENT OF

RESPIRATORY SYMPTOMS.

AND THESE ARE THE

RECOMMENDATIONS FOR PERSONS

EXPOSED TO SARS.

For THOSE WHO HAVE BEEN EXPOSED TO A

PERSON WITH SARS, OR TRAVELED IN

A GEOGRAPHIC AREA AFFECTED BY

SARS, SUCH AS CHINA AND HONG

KONG, WE RECOMMEND NO CHANGE IN

DAILY ACTIVITIES. HOWEVER, THESE INDIVIDUALS

SHOULD MONITOR THEMSELVES FOR

DEVELOPMENT OF RESPIRATORY

SYMPTOMS OR FEVER, INCLUDING

MEASURING THEIR TEMPERATURE

TWICE DAILY IN THE MORNING AND

EVENING. IF NO SYMPTOMS DEVELOP,

MONITORING MAY END TEN DAYS

AFTER THE LAST EXPOSURE.

HOWEVER, IF DURING THIS TIME

FEVER OR RESPIRATORY SYMPTOMS

DEVELOP, THE HEALTH CARE

PROVIDER SHOULD BE NOTIFIED AND

SHOULD CONSIDER WHETHER TO

EVALUATE THE PATIENT IMMEDIATELY

OR WAIT TO SEE IF THEY PROGRESS

TO SARS. DURING THIS TIME, THE PATIENT

SHOULD BE ADVISED TO BEHAVE AS

IF HE OR SHE DOES HAVE SARS, AND

LIMIT ACTIVITIES OUTSIDE THE

HOME. AT THE END OF 72 HOURS, THE

PATIENT\'S SYMPTOMS SHOULD BE

ASSESSED.

THIS ALGORITHM IS INCLUDED IN

OUR GUIDANCE ABOUT THE

MANAGEMENT OF PERSONS WITH

SARS-LIKE SYMPTOMS. AS YOU CAN SEE, IN THE MIDDLE

BOX, FOR THOSE PERSONS WHO ARE

IN THE 72-HOUR OBSERVATION

PERIOD, THERE ARE THREE POSSIBLE

OUTCOMES. ONE IS THAT THE SYMPTOM HAS

RESOLVED, OR SUBSTANTIALLY

IMPROVED, IN WHICH CASE SARS IS

UNLIKELY. THESE INDIVIDUALS MAY RETURN TO

DAILY ACTIVITIES BUT SHOULD

CONTINUE TO SELF-MONITOR FOR THE

FULL TEN DAYS FOLLOWING THEIR

LAST EXPOSURE. ANOTHER IS THAT THERE IS

PROGRESSION OF DISEASE THAT

MEETS THE CASE DEFINITION FOR

SARS, IN WHICH CASE, CLINICAL

EVALUATION FOR SARS SHOULD BE

PERFORMED.

IF HOSPITALIZATION IS NOT

REQUIRED, THE PATIENT SHOULD

FOLLOW THE HOME INFECTION

CONTROL RECOMMENDATIONS FOR SARS

PATIENTS THAT I WILL DISCUSS

SHORTLY.

HOWEVER, THERE WILL BE A GROUP

OF PATIENTS WHO ARE STILL

SYMPTOMATIC AFTER 72 HOURS

BUT DO NOT MEET THE CASE

DEFINITION. IN THIS SITUATION, CDC

RECOMMENDS CONTINUED LIMITATION

OF ACTIVITIES OUTSIDE THE HOME,

AND A REASSESSMENT IN ANOTHER 72

HOURS. IF AT THAT TIME THE PATIENT HAS

NOT PROGRESSED TO MEET THE CASE

DEFINITION, DISCONTINUATION OF PRECAUTIONS

CAN BE CONSIDERED AFTER

CONSULTATION WITH THE EVALUATING

CLINICIAN AND LOCAL PUBLIC

HEALTH AUTHORITIES.

FACTORS THAT SHOULD BE

CONSIDERED INCLUDE THE NATURE OF

THE POTENTIAL EXPOSURE TO SARS,

THE NATURE OF CONTACT WITH

OTHERS IN THE RESIDENTIAL OR

WORK SETTING, AND EVIDENCE FOR

AN ALTERNATIVE DIAGNOSIS.

THE FOLLOWING ARE RECOMMENDED

INFECTION CONTROL MEASURES FOR

PERSONS WITH SARS WHO DO NOT

REQUIRE HOSPITALIZATION, AND FOR

THOSE WHO MAY HAVE SYMPTOMS OF

SARS BUT ARE NOT YET DIAGNOSED.

THESE INDIVIDUALS SHOULD LIMIT

INTERACTIONS OUTSIDE THE HOME TO

THE EXTENT POSSIBLE.

IF TRAVEL OUTSIDE IS NECESSARY,

SUCH AS FOR MEDICAL CARE, A

SURGICAL MASK SHOULD BE WORN and

USE OF PUBLIC TRANSPORTATION

SHOULD BE AVOIDED.

ALSO BY LIMITING PERSONS COMING

INTO THE HOME, OTHER EXPOSURES

WILL BE AVOIDED.

THERE ARE SEVERAL COMMON-SENSE

MEASURES THAT CAN BE FOLLOWED TO

LIMIT SPREAD OF SARS IN THE

HOME. WITH THE EXCEPTION OF USING A

SURGICAL MASK, THESE APPLY TO

OTHER COMMON RESPIRATORY

INFECTIONS. FOR SARS, USE OF A SURGICAL MASK

WITHIN THE PRESENCE OF OTHERS IN

THE HOUSEHOLD IS RECOMMENDED.

IN ADDITION, RESPIRATORY

SECRETIONS MAY BE CONTROLLED BY

COUGHING INTO FACIAL TISSUES

THAT ARE THEN PLACED IN LINED

CONTAINERS FOR DISPOSAL WITH

HOUSEHOLD WASTE. HAND HYGIENE FOR ALL PERSONS IN

THE HOME IS ESSENTIAL.

AND PATIENTS WITH SARS SHOULD

PAY SPECIAL ATTENTION TO HAND

WASHING OR USING AN

ALCOHOL-BASED HAND GEL AFTER

TOUCHING RESPIRATORY SECRETIONS,

AND OTHER BODY FLUIDS, SUCH AS

URINE AND STOOLS.

HOUSEHOLD MEMBERS ALSO SHOULD

PROTECT THEMSELVES FROM

EXPOSURES.

IF THE PATIENT CANNOT WEAR A

MASK, THEN THE SURGICAL MASK

SHOULD BE WORN BY FAMILY MEMBERS

WHEN IN THE SAME ROOM AS THE

PATIENT WITH SARS.

HAND HYGIENE SHOULD BE PERFORMED

FREQUENTLY, PARTICULARLY AFTER

TOUCHING SURFACES THAT MAY BE

CONTAMINATED.

AND FAMILY MEMBERS MAY CONSIDER

WEARING DISPOSABLE GLOVES FOR

CONTACT WITH BODY FLUIDS OF SARS

PATIENTS.

OTHER INFECTION CONTROL MEASURES

ARE ALSO IMPORTANT, SUCH AS NOT

SHARING PERSONAL ITEMS, AND

CLEANING SURFACES THAT ARE

TOUCHED FREQUENTLY, SUCH AS FOOD

PREPARATION AREAS, PHONES AND

LAVATORIES.

CLEANING AGENTS NORMALLY USED IN

THE HOME ARE APPROPRIATE FOR

SARS.

MANUFACTURER RECOMMENDATIONS FOR

USE OF EACH PRODUCT SHOULD BE

FOLLOWED.

SOLUTIONS OF BLEACH CAN ALSO BE

USED FOR CLEANING AND

DISINFECTION.

A 1- TO -100 DILUTION OF BLEACH IN

WATER WHICH TRANSLATES INTO

ABOUT A QUARTER OF A CUP OF

BLEACH PER GALLON OF WATER CAN

BE USED FOR THIS PURPOSE.

CLINICIANS WILL PLAY AN

IMPORTANT ROLE IN ADDRESSING THE

FEARS AND OTHER CONCERNS OF

FAMILY MEMBERS.

ONE WAY THEY CAN HELP IS BY

ANTICIPATING AND DISCUSSING THE

NEEDS THAT ARE NOT IMMEDIATELY

OBVIOUS, FOR EXAMPLE, HOW A PATIENT WILL

OBTAIN FOOD, MEDICINE, AND OTHER

SUPPLIES, INCLUDING SURGICAL

MASKS, DURING THEIR PERIOD OF

CONFINEMENT; HOW WILL TRAVEL FOR NECESSARY

APPOINTMENTS BE ARRANGED; HOW SHOULD THEY DEAL WITH FAMILY

MEMBERS AND NEIGHBORS WHO MAY BE

AFRAID AND DON\'T WANT THEM IN

THE HOME OR EVEN IN THE

NEIGHBORHOOD.

ALTHOUGH THESE MAY SEEM LIKE

MINOR DETAILS, THEY MAY BE

DETERMINANTS IN WHETHER A

PERSON OR OTHER PERSONS BECOME

EXPOSED TO SARS.

THANK YOU FOR YOUR ATTENTION.

AND I ENCOURAGE YOU TO VISIT THE

CDC WEB SITE FOR ADDITIONAL

INTERIM INFECTION CONTROL

GUIDANCE ON SARS.

\>\> THANK YOU, LINDA CHIARELLO.

BUT WE HAVE NOW COME TO THE

Q & A PORTION OF THE PROGRAM.

THE NUMBERS TO CALL ARE BY PHONE

800-793-8598.

TTY, 800-815-8152.

AND BY FAX, 800-553-6323.

DR. JAMES LE DUC is DIRECTOR

OF THE DIVISION OF VIRAL

AND RICKETTSIAL DISEASES

AT THE NATIONAL CENTER

FOR INFECTIOUS DISEASES

AT THE CENTERS FOR DISEASE

CONTROL. He WILL BE ANSWERING

YOUR QUESTIONS ALONG

WITH THE REST OF OUR PANEL,

THE ONES THAT YOU\'VE ALREADY

BEEN INTRODUCED TO.

WELCOME TO DR. LE DUC.

AND WE\'LL GET STARTED WITH A

QUESTION RIGHT OFF THE TOP out

OF PALM BAY, FLORIDA. DR. LE DUC, THE QUESTION IS, HOW

LONG DOES THE CORONAVIRUS LIVE

OUTSIDE OF THE BODY.

\>\> THAT\'S A VERY GOOD QUESTION.

UNFORTUNATELY, WE DON\'T HAVE A

WHOLE LOT OF INFORMATION.

BUT AS WE CONTINUE TO LEARN MORE

ABOUT THIS VIRUS, IT\'S CLEAR

THAT THIS VIRUS SURVIVES QUITE

WELL IN THE ENVIRONMENT AS

COMPARED TO SIMILAR RNA VIRUSES.

IT LOOKS LIKE AT LEAST OVERNIGHT

ON SOME SURFACES, PERHAPS MUCH

LONGER IN SOME BODILY FLUIDS.

SO CLEARLY THE RECOMMENDATIONS

THAT LINDA HAS SHARED WITH US

ABOUT CLEANLINESS AND WASHING UP

ARE GOING TO BE CRITICALLY

IMPORTANT.

\>\> Kysa: WE\'RE TALKING ABOUT,

LIKE YOU SAID, PRETTY BASIC

THINGS.

BUT HERE\'S A QUESTION OUT OF

FORT LAUDERDALE, FLORIDA.

BESIDES HAND HYGIENE, ARE THERE

OTHER RECOMMENDATIONS FOR PEOPLE

WHO HANDLE PACKAGES FROM SARS

INFECTED AREAS?

\>\> KYSA, WE HAVE NO INFORMATION

THAT PACKAGES OR OTHER MATERIALS

THAT ARE SENT THROUGH THE MAIL

WOULD POSE A RISK FOR SARS

TRANSMISSION.

IF WE THINK BACK TO WHAT

DR. JERNIGAN SAID ABOUT

TRANSMISSION, IT REALLY DOES

REQUIRE very CLOSE CONTACT WITH AN

INFECTED INDIVIDUAL.

SO WE DO NOT HAVE

RECOMMENDATIONS FOR SPECIAL

HANDLING OF ANY PACKAGES, AND

OTHER THAN GOOD HYGIENE, HAND

HYGIENE THAT WOULD APPLY TO

ANYTHING THAT MAY BE SOILED,

THAT\'S WHAT WE WOULD RECOMMEND.

\>\> Kysa: OKAY.

ANOTHER QUESTION OUT OF

MISSISSIPPI THIS TIME.

IS IT TRUE THAT THERE ARE OR

HAVE BEEN PROBABLE CASES OF SARS

IN WHICH THERE WAS NO EVIDENCE

OF CORONAVIRUS INFECTION?

IS THIS TRUE?

DR. LE DUC?

\>\> AS DR. JERNIGAN INDICATED,

AND DEAN ERDMAN CONFIRMED, THIS

IS PRIMARILY A CLINICAL

DIAGNOSIS.

HOWEVER, CONSEQUENTLY, THERE CAN

BE A LOT OF SIMILAR-LOOKING

DISEASES THAT MIGHT BE CAUSED BY

OTHER AGENTS.

I DON\'T KNOW, JOHN, IF YOU WANT

TO FOLLOW UP ON THAT.

\>\> UNFORTUNATELY, EARLY IN THIS

OUTBREAK WHEN WE DON\'T HAVE

WIDESPREAD ACCESS TO DIAGNOSTIC

TESTS, WE\'RE STUCK WITH A VERY

NONSPECIFIC CASE DEFINITION.

AND IT\'S CLEAR THAT LARGE

PROPORTIONS OF THE PEOPLE WHO

FIT THE CASE DEFINITION FOR SARS

ARE NOT GOING TO BE INFECTED

WITH THE SARS-ASSOCIATED

CORONAVIRUS.

HERE IN THE UNITED STATES, AGAIN

ALTHOUGH WE\'RE STILL TESTING

MANY INDIVIDUALS, A VERY SMALL

PROPORTION OF THOSE WHO HAVE MET

THE case DEFINITION ACTUALLY HAVE

EVIDENCE FOR THE INFECTION.

\>\> Kysa: AND DR. JERNIGAN, THIS

COMES OUT OF COLORADO.

IT SAYS thAT YOUR SLIDE, I BELIEVE

THIS WAS YOUR SLIDE, SAID THAT

SARS TRANSMISSION CAN OCCUR

BEFORE EITHER FEVER OR

RESPIRATORY SYMPTOMS OCCUR.

CAN YOU TELL ME, THE CALLER, IF

TRANSMISSION CAN OCCUR BEFORE

ANY SYMPTOMS ARE APPARENT?

\>\> I THINK, WHAT I\'VE TRIED TO

CONVEY IS THAT THERE IS A PERIOD

OF ILLNESS BEFORE WHICH

RESPIRATORY SYMPTOMS START.

PATIENTS MAY HAVE FEVER,

HEADACHE, MYALGIAS, MALAISE for

THREE to seven DAYS BEFORE

RESPIRATORY SYMPTOMS START.

THERE IS EPIDEMIOLOGIC

EVIDENCE to suggest THAT IN THAT TWO OR

THREE DAYS or more before respiratory symptoms start, TRANSMISSION CAN

OCCUR.

THERE\'S NO epidemiologic EVIDENCE THAT

ASYMPTOMATIC PATIENTS ACTUALLY

TRANSMIT THIS DISEASE.

\>\> Kysa: OKAY.

NEW YORK.

IS THERE AN ICD-9 CODE FOR SARS?

DR. LE DUC?

\>\> I DON\'T BELIEVE THERE IS.

\>\> Kysa: MOVING RIGHT ON.

OUT OF LOUISIANA THIS TIME.

CAN YOU PROVIDE ANY ADDITIONAL

INFORMATION ON WHY CERTAIN

PEOPLE APPEAR TO BE SUPER

SHEDDERS OR SUPER INFECTORS?

\>\> AGAIN, THE concept OF THE

SUPER SPREADER OR SUPER SHEDDER

IS AN INTERESTING ONE.

I THINK WE HAVE A LOT MORE epidemiologic WORK

TO DO TO EXPLAIN THAT

PHENOMENON.

AS I SAID, THERE ARE POTENTIAL

FACTORS THAT COULD BE INVOLVED

THAT MIGHT INCLUDE THE HOST,

WHETHER there are HOST FACTORS

THAT ALLOW FOR VERY HIGH VIRAL

REPLICATIONS.

IT\'S POSSIBLE THAT THERE ARE

CHANGES IN THE PATHOGEN, FROM

TRANSMISSION TO TRANSMISSION.

ARE THERE GENETIC VARIABLES THAT

IN THE VIRUS ITSELF THAT CHANGE

ITS PATHOGENICITY or its communicability.

Its also possible that THERE MAY BE ENVIRONMENTAL

FACTORS THAT PLAY A ROLE.

AS WE've SAID ALREADY, IN a

HOSPITAL THERE ARE PLENTY OF

OPPORTUNITIES FOR TRANSMISSION, and

THERE MAY BE FACTORS ASSOCIATED

WITH AEROSOL GENERATING EVENTS

THAT CAN LEAD TO A HIGHER communicability or

ABILITY TO TRANSMIT THE VIRUS.

IT MAY BE A COMBINATION OF

THESE.

I THINK WE NEED A LOT MORE

INFORMATION AND STUDIES BEFORE

WE CAN FULLY UNDERSTAND THIS.

THERE IS SOME EVIDENCE OUT OF

HONG KONG ANECDOTALLY THAT SUPER

SPREADERS TEND TO HAVE very HIGH

COPIES OF THE VIRUS IN THEIR

RESPIRATORY SECRETIONS.

WHETHER THIS TURNS OUT TO BE

TRUE, WE\'LL HAVE TO WAIT AND

SEE.

\>\> Kysa: CERTAINLY A LOT TO

LEARN, AS YOU SAID.

THIS QUESTION IS OUT OF

NEBRASKA.

AND DR. ERDMAN, I THINK IT\'S ONE

THAT YOU CAN ANSWER.

HOW WILL THE SEQUENCING OF THE

CORONAVIRUS GENOME HELP WITH

TREATMENT.

\>\> I THINK IN THE FUTURE, THIS

COULD HAVE SOME UTILITY.

CERTAIN DRUGS, OF COURSE, target the nucleic acid in

THE VIRUS. IN UNDERSTANDING THAT

SEQUENCE AND HOW THOSE TARGETS

ARE IMPORTANT,

WILL BE OF CONSEQUENCE.

ALSO, AS TREATMENTS ARE APPLIED,

WE CAN SEE IF CHANGES OCCUR IN

THAT GENOME THAT MAY REFLECT THE

VIRUS ADAPTING TO, OR BECOMING

RESISTANT TO, THAT PARTICULAR

DRUG.

\>\> Kysa: OKAY.

OUT OF MONTREAL, CANADA.

DR. LE DUC, CAN YOU please COMMENT ON

THE EPIDEMIOLOGICAL AND

CLINICAL ASPECT OF PEDIATRIC

SARS?

\>\> THAT\'S AN EXCELLENT QUESTION.

IT APPEARS WHEN WE LOOK AT THE

CASES THAT OCCURRED \-- HAVE

OCCURRED AROUND THE WORLD, THAT

CHILDREN ARE LESS FREQUENTLY

INFECTED, AT LEAST LESS

FREQUENTLY HOSPITALIZED WITH

SARS AS COMPARED TO ADULTS.

SO IT APPEARS THAT THEY HAVE A

MILDER ILLNESS, ALTHOUGH THERE\'S

REALLY VERY LITTLE DATA TO GO

ON.

\>\> Kysa:

THIS IS OUT OF DELAWARE.

AND WE WERE JUST LOOKING AT

THIS.

SHOULD RESPIRATORS BE FIT

TESTED.

AND IF SO, WHERE DO I FIND

INFORMATION ABOUT FIT TESTING?

\>\> WELL, INFORMATION ON FIT

TESTING IS AVAILABLE ON THE CDC

WEB SITE.

AND NIOSH HAS PROVIDED A very

COMPREHENSIVE RESOURCE OF

INFORMATION ABOUT THAT FIT

TESTING PROCESS.

SO THAT ANSWERED THE SECOND

PART OF THE QUESTION.

IS FIT TESTING IMPORTANT?

YES, IT IS.

A RESPIRATOR IS PART OF A TOTAL,

COMPREHENSIVE RESPIRATORY

PROTECTION PROGRAM.

IT\'S VERY IMPORTANT THAT the respirator

PROVIDE A SEAL AROUND THE FACE

SO AIR IS NOT BEING INTRODUCED

INAPPROPRIATELY DURING WEARING

OF THAT DEVICE.

OTHERWISE IT IS NOT A

RESPIRATORY

PROTECTIVE DEVICE.

\>\> Kysa: I\'M NOT QUITE SURE WHO

TO DIRECT THIS QUESTION TO.

IS THERE ANYTHING SPECIFIC TO

LOOK FOR IN AN AUTOPSY?

\>\> MOST OF THE DATA WE HAVE FROM

PATIENTS WHO HAD

POST-MORTEM EXAMINATIONS, THE

SPECIFIC FINDINGS HAVE BEEN

PRIMARILY DIFFUSE ALVEOLAR

DAMAGE CONSISTENT WITH ARDS,

A VERY NONSPECIFIC FINDING.

THERE DOESN\'T APPEAR TO BE, AT

LEAST ON GROSS HISTOPATHOLOGY,

OR ROUTINE histopathologic EXAMINATION, MUCH

INVOLVEMENT OF TISSUES OUTSIDE

THE RESPIRATORY TRACT.

SO THE MAJOR HISTOPATHOLOGIC

FINDING and finding on autopsy HAS been DIFFUSE ALVEOLAR

DAMAGE IN THE LUNGS.

\>\> Kysa: ANOTHER HYGIENIC

QUESTION OUT OF FRESNO,

CALIFORNIA, THIS TIME.

HOW DO YOU CLEAN GOGGLES, OR

SHOULD THEY, TOO, BE INDIVIDUAL

USE?

I\'M NOT QUITE SURE I UNDERSTAND

THAT.

DO YOU UNDERSTAND THAT?

\>\> CERTAINLY, IF THEY\'RE GOING

TO BE USED FROM ONE HEALTH CARE

WORKER TO ANOTHER, THEY NEED TO

BE CLEANED using disinfectant.

AND \--

\>\> Kysa: OKAY.

\>\> BETWEEN USES.

IN TERMS OF THE CLEANING PROCESS

ONE WOULD HOPE THAT IN ANY

HEALTH CARE FACILITY, THE

PROCEDURES FOR CLEANING REUSABLE

EQUIPMENT AFTER USE IN AN

ISOLATION AREA WOULD BE IN

PLACE.

AND SO THE NORMAL MEASURES FOR

REPROCESSING USED GOGGLES AND

OTHER PERSONAL PROTECTIVE

EQUIPMENT SHOULD BE USED.

AND THAT WOULD BE THE CLEANING

AND DISINFECTION OF THAT

EQUIPMENT.

\>\> Kysa: OKAY.

AND IF WE CAN GET ANOTHER

QUESTION OVER HERE QUICKLY.

MOVE RIGHT ON.

OKAY.

THIS ONE, IT\'S MY UNDERSTANDING

VARIOUS CLEANSING AGENT CAN KILL

THE VIRUS.

CAN YOU BE MORE SPECIFIC ON WHAT

TYPES AND HOW TO USE?

\>\> THERE\'S A LOT OF WORK GOING

ON IN THIS AREA.

AND WE DON\'T HAVE ALL THE

ANSWERS YEt.

THIS IS A lipid envelope VIRUS, and BASED ON

EXPERIENCE WE HAVE WITH OTHER

lipid envelope VIRUSES, WE THINK THAT

MOST DETERGENTS SHOULD BE ABLE

TO TAKE CARE OF THIS VIRUS.

AND CERTAINLY, WE HAVE NO REASON

TO BELIEVE THAT EPA REGISTERED

DISINFECTANTS THAT ARE USED

COMMONLY IN THE HOME OR IN THE

HEALTH CARE SETTING WOULD NOT BE

ADEQUATE FOR THIS VIRUS.

Again, THERE ARE A NUMBER OF

ENVIRONMENTAL STUDIES GOING ON,

AND WE HOPE TO HAVE MORE

INFORMATION ON THIS IN THE

FUTURE.

IN GENERAL, THERE\'S NO REASON TO

BELIEVE THIS VIRUS WOULD BE

PARTICULARLY HARD TO ELIMINATE

FROM AN ENVIRONMENTAL SURFACE

WITH PRETTY ROUTINE CLEANING

MEASURES.

\>\> Kysa: WITH SUMMER APPROACHING

HERE\'S A TIMELY QUESTION.

IS THERE ANY EVIDENCE OF HOW \--

OR IF THE SARS VIRUS CAN LIVE IN

WATERWAYS?

\>\> I THINK THIS IS AN EXCELLENT

QUESTION.

AND ONE THAT WE\'LL BE TRYING TO

SYSTEMATICALLY ANSWER IN

THE FUTURE.

GIVEN THAT AS KYSA SAID, THE

WARMER MONTHS ARE AHEAD OF US.

WE DON\'T REALLY KNOW THE ANSWER

TO THAT QUESTION YET, BUT WE\'LL

CERTAINLY BE LOOKING INTO IT.

\>\> Kysa: THIS IS OUT OF MARYLAND

THIS QUESTION.

IT WAS MENTIONED THAT INITIAL

CHEST X-RAYS IN SARS MAY BE

NORMAL.

IS IT, THEREFORE, NECESSARY TO

OBTAIN FOLLOW-UP CHEST X-RAYS?

\>\> YEAH, I THINK SO.

IF YOU HAVE A PATIENT WHO HAS

THE RIGHT EPIDEMIOLOGIC

EXPOSURE AND HAS AN ILLNESS

THAT\'S CONSISTENT yet HAS A

NORMAL CHEST X-RAY ON ADMISSION,

IF YOU\'RE STILL HIGHLY

SUSPICIOUS THAT THIS PATIENT MAY

HAVE SARS, I THINK AN

APPROPRIATE MEASURE WOULD BE TO

FOLLOW UP WITH SERIAL CHEST

X-RAYS.

\>\> Kysa: THE QUESTIONS CONTINUE

TO COME IN.

IS THERE EVIDENCE OF REINFECTION

WITH SARS?

\>\> IT\'S EARLY IN THE OUTBREAK.

AND WE DON\'T HAVE A LOT OF

INFORMATION there.

THERE IS EVIDENCE FROM OTHER

HUMAN CORONAVIRUSES THAT

REINFECTION CAN OCCUR.

AND IT\'S QUITE POSSIBLE THAT

THAT MIGHT BE THE SAME WITH THIS

CORONAVIRUS.

BUT I THINK IT\'S JUST TOO EARLY

TO TELL YET.

\>\> Kysa: CERTAINLY A LOT OF

PEOPLE, AND WE\'VE TOUCHED ON

THIS, ARE A LITTLE LEERY, in particular you did.

THIS CALLER WANTS TO KNOW, IF

SOMEONE IS DIAGNOSED WITH SARS,

AND THEY WERE SITTING, SAY, IN A

CROWDED OR A WAITING ROOM,

SHOULD THE PATIENTS THAT WERE IN

THE WAITING ROOM WITH THEM BE

NOTIFIED THAT THEY WERE EXPOSED

TO SARS?

AND THEREFORE, BE QUARANTINED? Dr. Jernigan, Ms. Chiarello?

\>\> PERHAPS WE CAN BOTH ADDRESS

THIS.

\>\> SURE.

I THINK THE QUESTION BASICALLY

IS WHAT IS CLOSE CONTACT.

IF YOU LOOK AT OUR \-- THE MOST

RECENTLY released CASE DEFINITION, I

THINK WE ADDRESSED THIS.

AND CLOSE CONTACT IS DEFINED BY

REALLY PRETTY INTIMATE CONTACT,

THAT YOU MIGHT EXPECT IN THE

HOME, OR IF YOU\'RE HAVING CARED

FOR SOMEBODY, EITHER IN THE HOME

OR IN THE HEALTH CARE SETTING.

WE ALSO THINK THAT HAVING A

CLOSE FACIAL CONTACT DURING

CONVERSATION COULD BE INCLUDED

IN THAT LIST, OR SHARING EATING

UTENSILS, OR OTHER UTENSILS IN

THE HOME THAT MIGHT TOUCH THE

MUCOSAL SURFACES.

WE DON\'T THINK SITTING ACROSS

THE WAITING ROOM FOR A SHORT

PERIOD OF TIME PROBABLY

REPRESENTS AN EXPOSURE TO SARS.

I DON\'T KNOW IF YOU HAVE

ANYTHING TO ADD TO THAT, LINDA.

\>\> I think that's correct, and I THINK THE MESSAGE, TOO, IS

WE REALLY WANT TO ENCOURAGE

HEALTH CARE FACILITIES,

ESPECIALLY OUTPATIENT AREAS AND

EMERGENCY ROOMS, TO PUT IN THE

MEASURES IN PLACE FOR THE EARLY

detection OF SARS PATIENTS WHO MAY

BE COMING THROUGH.

THAT EARLY TRIAGE PROCEDURE, TO

IDENTIFY PERSONS WHO MAY HAVE

SYMPTOMS OF SARS, OR HAVE

TRAVELED OR HAD THE SARS

EXPOSURE.

AND THEN IF THERE ARE SYMPTOMS,

HAVING THAT INDIVIDUAL PUT ON A

SURGICAL MASK.

THAT\'S COMMON SOURCE CONTROL TO

PREVENT THE \-- HAVING THEM

COUGHING INTO THE ENVIRONMENT

AND EXPOSING OTHER INDIVIDUALS.

I THINK THAT\'S IMPORTANT.

\>\> Kysa: THE NEXT QUESTION, I\'M

NOT SURE THE DISEASE HAS BEEN

AROUND LONG ENOUGH FOR YOU TO

PROPERLY ANSWER THIS, BUT THE

PERSON WANTS TO KNOW, IS THERE

ANY EVIDENCE OR INFORMATION THAT

SARS AFFECTS PEOPLE SEASONALLY?

\>\> THAT\'S ANOTHER GOOD QUESTION

THAT WE REALLY DON\'T HAVE THE

ANSWER FOR YET.

CLEARLY THIS \-- THE EXPERIENCES

WE\'RE SEEING NOW ARE PRIMARILY

RESPIRATORY TRANSMISSION.

HOWEVER, AS WE ENTER WARMER

MONTHS IN THE NORTHERN

HEMISPHERE, THE POSSIBILITY OF

FECAL/ORAL TRANSMISSION IS VERY

REAL AND WE MAY IN FACT SEE A

SUMMERTIME PEAK AS WELL.

SO AT THIS POINT WE REALLY DON\'T

KNOW.

\>\> Kysa: AND DR. LE DUC, WHAT IS

THE DURATION OF THE ILLNESS THAT

WHY YOU\'RE SEEING FOR THOSE considered to have RECOVERED FROM SARS?

\>\> I THINK PROBABLY DR. JERNIGAN

IS A BETTER ANSWERERER OF THIS.

\>\> Kysa: SURE.

\>\> Again, WE\'RE LEARNING MORE ABOUT

THIS.

BUT IT DOES APPEAR THAT PATIENTS

CAN HAVE A MILD ILLNESS FOR A

PERIOD OF TIME BEFORE THEY

DEVELOP A SEVERE ILLNESS.

IT\'S POSSIBLE THAT PEOPLE MAY BE

ILL FOR AS LONG AS A WEEK OR SO

BEFORE THEY \-- IF THEY ARE \-- IF

THEY PROGRESS, BEFORE THEY

PROGRESS TO THE SEVERE STAGES.

I THINK, YOU KNOW, INTO THE

SECOND AND THIRD WEEK OF ILLNESS

PEOPLE ARE BEGINNING TO RECOVER

BY THAT TIME.

\>\> LET ME JUST ADD THAT IT

APPEARS THAT SOME PATIENTS ALSO

HAVE A PROLONGED CONVALESCENCE.

THEY DON\'T REALLY FEEL AS

THEMSELVES FOR QUITE SOME TIME.

\>\> Kysa: OKAY.

AND THIS QUESTION OUT OF

CALIFORNIA.

IS THERE ANY GROUP OF

INDIVIDUALS \-- ANY GROUP THAT IS

AT HIGHER RISK WHEN THEY TRAVEL

TO REGIONS WITH SARS?

ANY GROUP OF PEOPLE?

\>\> WELL, IT\'S HARD TO SAY,

BEFORE WE HAVE MORE EPIDEMIOLOGY what the actual risk factors are

OTHER THAN HAVING HAD DIRECT

CONTACT WITH A PATIENT WHO\'S

KNOWN OR SUSPECTED TO HAVE SARS.

\>\> Kysa: AND LET ME TRY TO WADE

THROUGH THIS ONE.

SHOULD INDUSTRIAL LAUNDRY REFUSE

SARS-SOILED LINEN, OR WHAT TPE

IS REQUIRED IF THE LINEN IS

ACCEPTED ON SITE.

\>\> I THINK, FIRST OF ALL, IT

WOULD BE DIFFICULT TO DETERMINE

WHAT LINEN MAY OR MAY NOT BE

SOILED FROM PATIENTS WITH SARS.

BECAUSE INFECTIOUS LINEN COMES

FROM MANY PATIENTS, AND IT JUST

DOESN\'T CONTAIN THE SARS VIRUS.

CDC RECOMMENDS THAT PROCEDURES

TO ROUTINELY HANDLE ALL LINEN AS

IF IT\'S POTENTIALLY CONTAMINATED

BEING PLACED IN HOSPITAL AND

INDUSTRIAL LAUNDRY CENTERS.

SO WE WOULD NOT RECOMMEND ANY

DIFFERENT \-- ANYTHING DIFFERENT

FOR THE HANDLING OF THE LINEN.

IT SHOULD BE PROPERLY BAGGED,

AND PERSONNEL IN THE COURSE OF

HANDLING ANY SOILED LINEN SHOULD

AVOID DIRECT CONTACT WITH THAT

MATERIAL, SHOULD AVOID ANYTHING

THAT WOULD AEROSOLIZE LINEN IN

GENERAL IN the course of HANDLING IT. So the

LIMITED HANDLING WITH ALL SOILED

LINEN IS WHAT WE WOULD NORMALLY

RECOMMEND.

\>\> Kysa: LET\'S SEE IF I\'M UP

WITH MY MEDICAL JARgON.

IT SAYS ADDRESS pre-HOSPITAL USE,

AND IN PARENTHESES, AMBOS, AND I'm thinking this is ambulances,

of nebulizer TREATMENT and OF INTUBATION.

DO AMBULANCE DRIVERS NEED TO

TAKE SPECIAL PRECAUTIONS.

\>\> THERE IS GUIDANCE ON OUR WEB

SITE SPECIFICALLY FOR

PRECAUTIONS DURING AMBULANCE

TRANSPORT OF PATIENTS.

AND THOSE PRECAUTIONS ARE VERY

SIMILAR TO THE ONES THAT HAVE

BEEN OUTLINED HERE.

AND I ENCOURAGE YOU TO CHECK THE

WEB SITE FOR A VERY DETAILED

LISTED OF THOSE.

THEY\'RE PRETTY BASIC USE OF

PERSONAL PROTECTIVE EQUIPMENT.

IF A PATIENT DID REQUIRE

INTUBATION, OR VENTILATION, IN

THAT SETTING, THOSE are AEROSOL

GENERATING EVENTS, AND IF

UNPROTECTED, THAT WOULD BE

CONSIDERED A HIGH-RISK EXPOSURE.

THE PROPER PERSONAL PROTECTIVE

EQUIPMENT IS RECOMMENDED.

AND HOW TO HANDLE THAT SITUATION

AFTER ONE MIGHT OCCUR WOULD HAVE

TO BE HANDLED ON A CASE-BY-CASE

BASIS.

BUT I WOULD ENCOURAGE YOU TO

VISIT OUR WEB SITE AND LOOK AT

THE GUIDANCE FOR PROTECTION AND

PRECAUTION TO TAKE DURING

AMBULANCE TRANSPORT.

\>\> Kysa: AND WHAT ARE SOME OF

THE HYPOTHESeS REGARDING THE

ORIGINATION OF THE VIRUS?

\>\> WELL, AS DR. ERDMAN SHARED

WITH US, THIS GROUP OF VIRUSES

IS VERY COMMON IN A NUMBER OF

DIFFERENT ANIMAL SPECIES.

SO CERTAINLY ONE HYPOTHESIS IS

THAT THIS VIRUS HAS SOME ORIGIN

IN ANIMALS, PERHAPS WILD ANIMALS,

AND IT\'S SOMEHOW BECOME

INTRODUCED INTO THE HUMAN

POPULATION PERHAPS AS A FOOD

SOURCE, OR WHO KNOWS HOW.

WE HAVE REALLY NO IDEA.

BUT IT\'S CERTAINLY AN INTRIGUING

AREA FOR FUTURE INVESTIGATIONS.

\>\> Kysa: AND NOW, SOMEONE FROM

CONNECTICUT WANTS TO KNOW, CAN

YOU GIVE MORE DETAILS ON

INFORMATION REPORTs ABOUT

RELAPSES OF PATIENTS?

\>\> WE, OF COURSE, IN THE PRESS,

IT WAS REPORTED A COUPLE OF

WEEKS AGO THAT THERE MAY HAVE

BEEN SOME RELAPSES IN HONG KONG.

I THINK THERE\'S SOME INFORMATION

SINCE THAT TIME THAT SUGGESTS

THAT THAT MAY NOT BE QUITE THE

CASE.

I CAN SAY THAT WE\'VE LOOKED AT

THE SMALL NUMBER OF PATIENTS

WE\'VE HAD HERE, AND HAVE NOT

SEEN ANY REAL RELAPSES

DESCRIBED.

I\'VE BEEN IN TOUCH WITH OUR

COLLEAGUES IN CANADA, AND THERE

HAVE NOT BEEN any RELAPSES

DESCRIBED IN THAT SETTING

EITHER.

SO I THINK WE NEED A LITTLE MORE

TIME TO SORT THAT OUT AND SEE

EXACTLY WHAT THE STORY ON THAT

IS.

RIGHT NOW, I DON\'T THINK THERE\'S

REAL SOLID EVIDENCE THAT THERE

ACTUALLY IS RELAPSE.

IT COULD BE THAT THIS IS A

MANIFESTATION OF WITHDRAWING

SOME OF THE IMMUNOSUPPRESSIVE

TREATMENTS and the CORTICOSTEROIDS and withdrawing other therapy,

BUT I THINK WE JUST

NEED MORE TIME TO SORT THAT OUT.

\>\> Kysa: THIS QUESTION DEALS

WITH SARS IN THE HOME.

HOW DO YOU DISPOSE OF MASKS AND

OTHER CONTAMINATED MATERIALS IN

THE HOME?

MS. CHIARELLO.

\>\> AT THE PRESENT TIME, WE ONLY

RECOMMEND THAT SOILED MATERIALS,

CONTAMINATED MATERIALS, BE BAGGED

AND DISPOSED WITH THE REGULAR

HOUSEHOLD WASTE, WHICH IS THE

SAME THING WE WOULD RECOMMEND

FOR ANY OTHER INFECTIOUS

MATERIAL THAT WAS IN THE HOME.

SO THERE\'S NOTHING SPECIAL OR

DIFFERENT.

BUT IT IS IMPORTANT TO CONTAIN

THAT MATERIAL IN SOME KIND OF

PLASTIC BAG FOR DISPOSAL.

AND THEN PUT IT WITH THE REGULAR

TRASH.

\>\> Kysa: GETTING A LOT OF

QUESTIONS OUT OF CALIFORNIA.

HOW LONG ARE SURGICAL MASKS

PROTECTIVE?

\>\> I THINK THE QUESTION IS

REALLY, HOW LONG CAN ONE WEAR A

SURGICAL MASK, OR A RESPIRATOR

IF THAT\'S WHAT THEY\'RE USING.

AND WE GENERALLY RECOMMEND THAT

MASKS, SURGICAL MASKS AND

RESPIRATORS BE DISPOSED AFTER A

SINGLE USE.

NOW, IN THE HOME SETTING, THIS

MAY NOT BE PRACTICAL.

AND SO WITHIN THE HOME, IT

SHOULD BE SINGLE-PERSON USE,

FIRST OF ALL.

AND THEN WHEN THEY BECOME SOILED

OR MOIST, THAT\'S THE APPROPRIATE

TIME.

WE DON\'T HAVE A SPECIFIC

HOUR TIME, OR HOURLY TIME

INTERVAL AFTER WHICH THEY\'RE NO

LONGER EFFECTIVE.

BUT THEY DO BECOME SOILED AND WE

WOULD RECOMMEND AT LEAST

DISPOSING OF THEM ON A DAILY

BASIS.

AND THE SAME THING WOULD APPLY

IN A HEALTH CARE SETTING,

DISPOSING OF THEM AFTER SINGLE

USE IS PREFERRED.

IF THEY ARE REUSED, DISPOSING OF

THEM IDEALLY AT THE END OF THE

DAY WOULD BE THE PREFERRED

OPTION.

\>\> Kysa: OKAY.

AND A PERSON OUT OF WISCONSIN

WRITES, EMERGENCY ROOMS DON\'T

HAVE ANY NEGATIVE AIR PRESSURE.

THE QUESTION IS, WHAT MEASURES

SHOULD BE TAKEN?

\>\> THIS REALLY GOES BACK TO WHAT

I MENTIONED EARLIER, IN TERMS OF

THE SOURCE CONTROL CONCEPT AND

HAVING PATIENTS WHO ARE

SYMPTOMATIC WITH SARS, AND EVEN

ANY RESPIRATORY DISEASE, REALLY,

COULD BE PUTTING ON A SURGICAL

MASK TO PROTECT THEMSELVES, SO that

THERE IS THAT SOURCE CONTROL.

WITHIN THE EMERGENCY ROOMS, MANY

DON\'T HAVE THE NEGATIVE PRESSURE

ENVIRONMENT AS MIGHT BE USED IN

AN INPATIENT SETTING.

AND IT\'S POSSIBLE THROUGH THE

SOURCE CONTROL, AND THROUGH

OTHER \-- TRYING TO ALTER THE

VENTILATION IN THAT ROOM SO THAT

BY PUTTING THE PATIENT PERHAPS

IN AN AREA WHERE THEY\'RE MORE

REMOVED FROM OTHER PATIENTS, A

DISTANCE AWAY, HAVING THE HEALTH

CARE PERSONNEL WEAR THE

RECOMMENDED PROTECTIVE ATTIRE,

AND JUST TRYING TO PROVIDE A

SPACE FOR THOSE INDIVIDUALS.

WE HAVE SAID THAT IF IT\'S

POSSIBLE, TO EXHAUST THE AIR TO

THE OUTSIDE.

BUT I REALIZE THAT THAT\'S NOT A

VERY PRACTICAL SOLUTION.

AT LEAST FOR EMERGENCY ROOMS.

\>\> Kysa: DR. JERNIGAN?

\>\> If I could add to that, I JUST WANT TO EMPHASIZE THAT

ALTHOUGH WE\'RE still LEARNING ABOUT

THE EPIDEMIOLOGY AND

TRANSMISSION OF THIS ILLNESS,

MOST OF THE TRANSMISSION AND

MOST OF THE EPIDEMIOLOGY

SUGGESTS THAT TRANSMISSION

OCCURS IN THE VAST MAJORITY OF

CASES BY EITHER CLOSE CONTACT

WITH LARGE DROPLET AEROSOLS, OR direct contact or perhaps

INDIRECT CONTACT.

AIRborne TRANSMISSION DOESN\'T

SEEM TO BE THE MAJOR MODE OF

TRANSMISSION.

THERE ARE certain SETTINGS THAT WE

TALKED ABOUT some TODAY, SPECIFICALLY

THESE AEROSOL GENERATING

PROCEDURES, WHERE THAT MAY BE A

PARTICULAR CONCERN.

EVEN IF YOU DIDN\'T HAVE A

NEGATIVE PRESSURE ROOM,

IDENTIFYING THE PATIENT QUICKLY,

PUTTING THEM IN A ROOM BY

THEMSELVES even if it's not negative pressure IS PROBABLY GOING TO

GO MOST OF THE WAY TOWARDS

PREVENTING OTHER TRANSMISSIONS.

IF THERE IS A NEED FOR AN

AEROSOL GENERATING PROCEDURE,

THEN IN THAT PARTICULAR CASE, I

MIGHT DEFER UNTIL YOU WERE IN A

NEGATIVE PRESSURE SETTING.

\>\> Kysa: AND WE HAVE A QUESTION

FROM FLORIDA.

WHAT IS THE OPINION OF THE PANEL

ON WHY WE HAVEN\'T SEEN ANY

DEATHS IN THE UNITED STATES?

THAT\'S AN EXCELLENT QUESTION.

\>\> WELL, IT\'S A GOOD QUESTION.

I\'LL TAKE A FIRST CRACK, AND

I\'LL SEE WHAT THE OTHERS SAY.

ONE POSSIBLE EXPLANATION is THAT WE

JUST HAVEN\'T SEEN THAT MANY REAL

CASES IN THE UNITED STATES.

WE\'VE ONLY HAD SIX LABORATORY

CONFIRMED CASES SO FAR

OF PATIENTS WITH SARS

CORONAVIRUS INFECTION.

AND HAVING NO DEATHS MAY NOT BE

SIGNIFICANTLY DIFFERENT FROM

WHAT\'S BEEN REPORTED IN SOME OF

THE OTHER COUNTRIES.

IT\'S ALSO POSSIBLE THAT THERE

MAY BE DIFFERENCES IN THE WAY

THAT WE \-- THE VIRUS HAS COME

INTO OUR COUNTRY.

IT\'S

POSSIBLE THAT THE SO-CALLED

SUPER SHEDDERS MAY BE, FOR

WHATEVER REASON, TRANSMITTING

HIGH NUMBERS OF VIRUS OR MAY BE

DIFFERENCES IN THE virulence of the STRAIN OF THE

VIRUS THAT THEY\'RE SPREADING.

WE DON\'T KNOW.

THOSE COULD BE RELATED TO

MORTALITY.

IT MAY JUST BE THAT WE HAVE NOT

HAD ANY OF THOSE PARTICULAR

INDIVIDUALS YET IN THIS COUNTRY.

WE SIMPLY DON\'T KNOW.

\>\> Kysa: WOULD YOU LIKE TO ADD

TO THAT, DR. LE DUC?

\>\> WELL, OF THose SIX PATIENTS,

ALL OF THEM HAD PNEUMONIA.

TWO OF THEM WERE IN ICUs, AND I

THINK ONE OF THEM AT LEAST

REQUIRED VENTILATION.

SO CLEARLY, THESE PATIENTS WERE

NOT SUFFERING FROM A MILD

ILLNESS.

I THINK SO FAR THE NUMBERS ARE

JUST SMALL, AND I SUSPECT THAT

OVER TIME WE\'RE LIKELY TO SEE A

FATALITY.

\>\> Kysa: OKAY.

LISA FROM CALIFORNIA WOULD LIKE

TO KNOW, IS CDC CONSIDERING

EXPANDING THE TEN-DAY PERIOD

AFTER EXPOSURE PER CURRENT CASE

DEFINITION?

\>\>There are NO PLANS THAT I\'M AWARE OF TO

EXPAND THAT NUMBER NOW.

AGAIN, FOR THOSE CASES IN WHICH

WE HAVE THE MOST WELL-DEFINED

EXPOSURES, IT SEEMS that THE

INCUBATION PERIOD DOES FALL IN

THAT THREE TO TEN-DAY PERIOD.

SO WE HAVE NO IMMEDIATE PLANS TO

CHANGE THAT RIGHT NOW.

\>\> Kysa: OKAY.

ANOTHER QUESTION FROM

CALIFORNIA.

SALLY.

WHAT ARE CONCERNS FOR

CONTAINMENT OF THE VIRUS PER

RECENT INFORMATION THAT THE

VIRUS MAY BE MUTATING?

\>\> I THINK THE UNMUTATED VIRUS

HAS \-- IS SUFFICIENT FOR

CONCERN.

AND I THINK THE EVIDENCE THAT

THE VIRUS IS MUTATING

SUBSTANTIALLY IS REALLY NOT

THERE YET.

WE\'RE WAITING TO SEE IF THIS IS

IN FACT THE CASE.

\>\> Kysa: VIRGINIA.

HAVE THEY SEEN OTHER OUTBREAKS

WITH THE CORONAVIRUS IDENTIFIED

IN THE PAST, AND WHAT HAS BEEN

THE CDC\'S RESPONSE?

\>\> WELL, AGAIN, THERE ARE OTHER

KNOWN HUMAN CORONAVIRUSES.

FORTUNATELY, THOSE CORONAVIRUSES tend to cause only a very

MILD UPPER

RESPIRATORY ILLNESS, SIMILAR TO

THE COMMON COLD.

THERE MAY HAVE BEEN, MAY BE SOME

ASSOCIATED WITH A FEW CASES OF

PNEUMONIA.

BUT IN GENERAL, IT\'S BEEN A MUCH

MORE MILD ILLNESS THAN WHAT

WE\'RE SEEING HERE.So

THERE\'S been REALLY BEEN NO NEED FOR

A MAJOR PUBLIC HEALTH RESPONSE

IN THE PAST.

\>\> Kysa: OUT OF NEW YORK, IS

THERE ANY EVIDENCE THAT SARS CAN

BE TRANSMITTED BY INSECTS?

I\'M NOT AWARE OF ANY.

\>\> I\'M NOT AWARE OF ANY

EVIDENCE.

\>\> Kysa: NO EVIDENCE?

\>\> LET ME JUST ADD, HOWEVER,

THAT THE FACT THAT WE\'RE NOW

SEEING EVIDENCE OF THE VIRUS

SURVIVING IN THE ENVIRONMENT,

BEING PRESENT IN FECES AND OTHER

BODILY FLUIDS, ALL OF THIS LENDS

ONE TO BELIEVE THAT GENERAL

HYGIENE ISSUES ARE CERTAINLY

IMPORTANT.

AND WE WANTED TO MAKE SURE THAT

ADEQUATE HYGIENE EFFORTS ARE IN

PLACE, ESPECIALLY AROUND KNOWN

CASES.

SO WE DON\'T WANT TO TEST THAT

HYPOTHESIS about insect transmission UNNECESSARILY.

\>\> Kysa: WHAT EVIDENCE EXISTS

THAT SARS INFECTION COULD BE

AIRBORNE?

\>\> WELL, AGAIN, THERE\'S \-- THE

EPIDEMIOLOGY THAT WE know OF

SO FAR WOULD SUGGEST THAT IN THE

VAST MAJORITY OF CASES,

TRANSMISSIONs were NOT BY THE

AIRBORNE ROUTE.

AGAIN, THERE ARE WORRISOME

EXAMPLES OF TRANSMISSION THAT

SUGGEST THAT AIRBORNE MAY HAVE

PLAYED A ROLE.

SOMETIMES IT CAN BE VERY

DIFFICULT epidemiologically TO SORT OUT AIRBORNE

TRANSMISSION from INDIRECT fomite

TRANSMISSION.

WE HAVE MORE EPIDEMIOLOGY TO DO.

AGAIN, IN GENERAL, WE THINK THE

MAJOR MODE OF TRANSMISSION IS either

LARGE DROPlets OF AEROSOL, COMING IN

close CONTACT WITH THE PATIENT,

OR DIRECT OR INDIRECT CONTACT. There are certain settings in which
aerosolize or

AIRBORNE TRANSMISSION CAN\'T BE

RULED OUT.

\>\> Kysa: ANOTHER QUESTION FROM

CALIFORNIA.

FOR PATIENTS WITH A POSITIVE

TRAVEL OR EXPOSURE HISTORY

WHO HAVE ONE SYMPTOM, DO THEY

NEED A FACE-TO-FACE EXAM OR

SHOULD THEY STAY HOME SIMPLY FOR

THE 72-HOUR WAIT-AND-SEE PERIOD?

\>\> I THINK IT\'S A GOOD QUESTION.

AND I THINK IT\'S A CLINICAL

JUDGMENT.

IF A PHYSICIAN TALKS TO A

PATIENT WHO HAS PERHAPS A MILD

ILLNESS, DOESN\'T SOUND LIKE THEY probably

MEET THE CASE DEFINITION

from talking to THEM OVER THE

PHONE, IT COULD BE APPROPRIATE

TO ADVISE THE PERSON OVER THE

PHONE AND THEN REEVALUATE AND

MAKE A CLINICAL JUDGMENT ON

WHETHER OR NOT ONE SHOULD

PRESENT TO AN OUTPATIENT SETTING

FOR EVALUATION.

I THINK IT IS IMPORTANT TO

COMMUNICATE THAT, IF A PATIENT

DOES FEEL LIKE THEY NEED TO

PRESENT FOR EVALUATION, THEY

SHOULD NOTIFY THEIR HEALTH

CAREGIVER IN ADVANCE SO THAT

PREPARATIONS CAN BE MADE TO MEET

THEM AND MAKE SURE THAT THE

APPROPRIATE INFECTION CONTROL

PRECAUTIONS ARE TAKEN AT THE

MOMENT THEY HIT THE DOOR,

INCLUDING PERHAPS PUTTING A MASK

ON THE PATIENT AND OTHER THINGS

THAT THE FACILITY MAY WANT TO

DO.

\>\> Kysa: SOMEONE FROM OKLAHOMA

WANTS TO KNOW, ARE THERE

ANTI-VIRAL DRUGS IN DEVELOPMENT

FOR THE SARS CORONAVIRUS?

\>\> WE\'RE WORKING VERY CLOSELY

WITH THE NATIONAL INSTITUTES OF

HEALTH AND OTHER LABORATORIES IN

EXAMINING ALL OF THE LICENSED

ANTI-VIRAL DRUGS CURRENTLY

MARKETED, AS WELL AS THOSE IN

THE PIPELINE TO SEE WHICH, IF

ANY, WILL BE SHOWN TO BE efficacious

IN TREATING THIS VIRUS.

SO FAR, WE DON\'T HAVE ANY HITS,

BUT THERE\'S LITERALLY THOUSANDS

OF COMPOUNDS THAT WE\'RE PLOWING

THROUGH.

\>\> Kysa: THIS IS A TRANSMISSION,

A TYPED QUESTION.

DOES TEMPERATURE OR HUMIDITY

HAVE AN EFFECT ON THE SURVIVAL

OF THE SARS VIRUS ON SURFACES?

\>\> WELL, THERE\'S BEEN LIMITED

STUDIES with THE HUMAN

CORONAVIRUSES, AND SOME OF THE

VARIABLES THEY\'VE LOOKED AT HAVE

BEEN TEMPERATURE, HUMIDITY, THE

TYPE OF SURFACE.

AND ALL OF THOSE DO INDEED

AFFECT THE SURVIVABILITY OF THE

VIRUS.

THOSE VARIABLES WILL BE LOOKED

AT IN THIS CASE AS WELL.

\>\> Kysa: THEN OUT OF CALIFORNIA,

DOES THE PANEL RECOMMEND THAT

E.R.s CLOSE FOR A CERTAIN PERIOD

OF TIME AFTER A SARS PATIENT HAS

BEEN IDENTIFIED?

\>\> AND I BELIEVE \-- ON MY PART, NO, I WOULD SAY

NO, WE HAVE NO RECOMMENDATION.

THAT THERE\'S ANY INDICATION TO

CLOSE AN EMERGENCY ROOM.

AS DR. JERNIGAN ALREADY

MENTIONED, IT REALLY IS A very CLOSE

CONTACT WITH PATIENTS.

AND WE DON\'T BELIEVE THAT THERE

IS AN INDICATION TO GO TO THAT

EXTREME AT THIS POINT IN TIME.

\>\> Kysa: GETTING A LOT OF GOOD

QUESTIONS IN.

THIS ONE IS, WHAT IS THE RISK TO

COMMERCIAL AIRLINES \-- WHAT IS

THE RISK ON COMMERCIAL AIRLINES

TO AND FROM afFECTED AREAS?

SAY someone flying FROM HONG KONG TO THE UNITED

STATES, OR VICE VERSA.

\>\> THAT\'S A VERY IMPORTANT

QUESTION.

THAT\'S BEING LOOKED AT BY A

NUMBER OF GROUPS AROUND THE

WORLD.

THERE ARE A NUMBER OF COHORT

STUDIES THAT ARE BEING CONDUCTED

IN AN INTERNATIONALLY

COLLABORATIVE WAY.

FLIGHTS IN WHICH PATIENTS WHO

HAD KNOWN OR SUSPECT SARS,

FLIGHTS ON WHICH THOSE PERSONS

TRAVELED.

THERE HAVE BEEN REALLY A VERY

LIMITED NUMBER OF DOCUMENTED

TRANSMISSIONS IN THAT SETTING.

AND WHEN YOU LOOK AT THE

DENOMINATORS OF THE PASSENGERS

WHO TRAVELED ON THOSE FLIGHTS,

IT WOULD APPEAR THAT THE RISK IS

VERY, VERY, VERY LOW.

HOWEVER, THOSE STUDIES ARE

ONGOING AND WE HOPE TO HAVE A

MORE QUANTITATIVE ASSESSMENT OF

THAT IN THE NEAR FUTURE.

\>\> Kysa: MARK FROM VERMONT WANTS

TO KNOW WHAT THE PANEL THINKS

ABOUT UNIVERSITIES AND THEIR

POLICIES WITH REGARD TO ASKING

STUDENTS TO WAIT TEN DAYS per

EXPOSURE.

AND HOW MUCH DO THEY TAKE IN

ACCOUNT LOCAL MEDICAL RESOURCES.

AND THEN WE HAVE ADVICE ON THIS

SITUATION, COLLABORATIVE EFFORT,

I GUESS THEY\'RE ASKING.

\>\> YES.

THAT\'S A VERY GOOD QUESTION.

AND CLEARLY IN THE NEWS

CURRENTLY.

I THINK THAT OUR GUIDANCE WOULD

BE SIMILAR TO THAT FOR PERSONS

THAT ARE ASYMPTOMATIC AND

POTENTIALLY EXPOSED.

I THINK MONITORING self\--TAKING

YOUR TEMPERATURE TWICE A DAY,

BEING COGNIZANT OF YOUR HEALTH,

WOULD BE APPROPRIATE.

I THINK AS STATED, WE WOULD NOT

INTERRUPT YOUR NORMAL DUTIES.

\>\> AND JUST TO ADD, I WOULD

AGREE WITH THAT, BUT TO ADD TO

THAT, I THINK WE ARE \-- WE DO

NEED TO FORMULATE SOME GUIDANCE

ON WHAT TO DO IF YOU\'RE

EXPECTING a LARGE INFLUX OF

PATIENTS WHO MIGHT BE

POTENTIALLY EXPOSED.

AND WE ARE GATHERING TOGETHER

WORKING GROUPS AS WE SPEAK TO

COME UP WITH BETTER DEFINITIVE,

MORE DEFINITIVE GUIDANCE ON

EXACTLY HOW TO HANDLE THE

SITUATION.

SO STAY TUNED, WE HOPE TO HAVE

SOME GOOD ANSWERS FOR YOU SOON.

\>\> Kysa: OUT OF WISCONSIN, HOW

BIG IS THE VIRUS?

AND THEN IN PARENTHESES,

MICRONS.

\>\> WE CONSIDER CORONAVIRUS, IT

CAN TAKE DIFFERENT SIZES AND

SHAPES.

BUT GENERALLY, Well, WE CONSIDER coronavirus like some other viruses
pleomorphic. IT can take different sizes and shapes. But generally we
consider it a

MODERATELY SIZED VIRUS,

SOMEWHERE BETWEEN 100 AND 150

NANOMETERS.

\>\> Kysa: Out of Ohio, DO SMOKERS HAVE A

HIGHER RISK FOR SARS?

AND IN PARENTHESES, ASIA, AND A

HIGH INCIDENCE?

I\'M NOT QUITE SURE \--

\>\> DON\'T REALLY KNOW THE ANSWER

TO THAT QUESTION.

I THINK WE\'LL HAVE TO WAIT FOR

SOME OF THE STUDIES FOR THE

PLACES THAT HAVE THE HIGHEST

NUMBERS OF CASES.

DON\'T REALLY KNOW YET.

\>\> Kysa: NEW YORK, FOR

AMBULANCES SERVICES.

SHOULD UTILIZEd NEBULIZERS

BE TAKEN OUT OF USE?

YES, SHOULD UTILIZED NEBULIZERS be

TAKEN OUT OF USE.

\>\> THEY SHOULD CERTAINLY BE

REPROCESSED AFTER USE ON ANY

PATIENTS.

THOSE ARE NOT THINGS THAT SHOULD

GO FROM ONE PATIENT TO ANOTHER

WITHOUT PROPER CLEANING AND

DISINFECTION. So in the sense that they're taken out of use for cleaning
and disinfection, yes. But

TAKEN OUT OF USE PERMANENTLY, I

WOULD SAY NO, THERE\'S NO

INDICATION THAT THERE\'S A NEED

TO DO THAT.

\>\> Kysa: ARE DISPOSABLE FOOD

TRAYS INDICATED FOR SARS

PATIENTS, EVEN THOUGH THIS IS

NOT PART OF CONTACT PRECAUTIONS?

\>\> NO, CDC HAS NEVER RECOMMENDED

THE USE OF DISPOSABLE DISHES OR

OTHER UTENSILS FOR PATIENTS WITH

SARS.

\>\> Kysa: AND THEN FROM KENTUCKY,

WHAT ARE THE SPECIAL PRECAUTIONS

FOR HANDLING TISSUE SPECIMENS OF

SUSPECTED SARS PATIENTS?

\>\> AGAIN, I THINK I WOULD REFER

YOU TO OUR WEB SITE.

THERE\'S AN EXTENSIVE DOCUMENT

THAT GIVES GUIDANCE FOR HANDLING

AND PROCESSING LABORATORY

SPECIMENS. For THE DETAILED DOCUMENT, I

WOULD SUGGEST THAT YOU VISIT THE

WEB SITE TO GET THAT ANSWER.

\>\> Kysa: IS IT POSSIBLE TO

STERILIZE N-95 MASKS TO REUSE

THEM, AND TO REUSE THEM AFTER

STERILIZATION?

\>\> Actually, THAT\'S A VERY GOOD QUESTION.

THEY PROBABLY CAN BE PHYSICALLY

STERILIZED.

BUt IT\'S PROBABLY NOT A GOOD

IDEA, BECAUSE IT MIGHT AFFECT

THE INTEGRITY OF THE RESPIRATOR

ITSELF.

AND YOU WOULD NOT WANT TO DO

THAT.

SO WE WOULD ADVISE AGAINST

TRYING TO REPROCESS N-95

RESPIRATORS.

THE REUSABLE RESPIRATORS CAN

CERTAINLY BE PREPROCESSED

THROUGH NORMAL CLEANING AND

DISINFECTIon PROCEDURES, BUT NOT

THE DISPOSABLE ones.

\>\> Kysa: AND OUT OF WISCONSIN,

IF SARS IS NOT AIRBORNE, WHY DO

WE NEED TO FIT TEST FOR MASKS

IN A CLINICAL TYPE SETTING?

\>\> WELL, AGAIN, AS I\'VE TRIED TO

INDICATE, WE\'RE STILL LEARNING

ABOUT THE MODEs OF TRANSMISSION.

IT\'S QUITE POSSIBLE AND PROBABLE

IN MY OPINION, THAT THERE ARE

MULTIPLE MODES OF TRANSMISSION.

ALTHOUGH THE MAJOR MODES ARE

PROBABLY LARGE DROPLET IN

CONTACT.

THERE ARE SETTINGS IN WHICH

WE\'RE CONCERNED THAT AIRBORNE

TRANSMISSION CAN TAKE PLACE.

PARTICULARLY SURROUNDING AEROSOL

GENERATING EVENTS.

IN PARTICULAR IN THOSE

SETTINGS THAT WE THINK A FULL

RESPIRATORY PROTECTION PROGRAM

SHOULD BE AVAILABLE.

\>\> Kysa: Out of Missouri, WHAT\'S RECOMMENDED FOR

PHYSICIANS AND MEDICAL STUDENTS

FROM AFFECTED AREAS REGARDING

POINT CONTACT?

\-- PATIENT-pt-, EXCUSE ME, PATIENT

CONTACT IN THIS COUNTRY?

\>\> AGAIN, I THINK THEY WOULD

FALL UNDER THE SAME GUIDANCE

THAT WE GIVE ANY HEALTH CARE

WORKER.

IF THEY\'VE HAD \-- AS LINDA

MENTIONED, IF THEY\'VE HAD AN

UNPROTECTED HIGH-RISK EXPOSURE,

UNPROTECTED, THEN WE ARE

RECOMMENDING ACTUALLY THAT THOSE

PATIENTS SHOULD \-- THOSE HEALTH

CARE WORKERS SHOULD BE EXCLUDED

FROM DUTY FOR A TEN-DAY PERIOD.

HOWEVER, IN THE ABSENCE OF THAT,

THEY SHOULD BE MONITORING THEMselves

FOR SIGNS AND SYMPTOMS OF

ILLNESS VERY CLOSELY, MEASURE

THEIR TEMPERATURE TWICE DAILY.

But AS LONG AS THEY\'RE ASYMPTOMATIC,

THEY SHOULD BE ALLOWED TO WORK.

\>\> Kysa: OKAY.

AND DR. JERNIGAN, ANOTHER

QUESTION FROM LINDA OUT OF NEW

YORK.

IT WAS STATED THERE IS VIRAL

SHEDDING FOR AS LONG AS 21 DAYS

POST-ILLNESS ONSET.

THEREFORE, WHEN IS A SARS

PATIENT CONSIDERED SARS NEGATIVE

AS IT RELATES TO THEM BEING A

POTENTIAL SOURCE FOR CONTINUING

SPREAD, I THINK IS THE WORD

HERE?

\>\> WELL, THIS IS OBVIOUSLY A

VERY CRITICAL QUESTION.

I SHOWED THOSE DATA.

AND I THINK THERE ARE A COUPLE

OF CAVEATS THERE,

NUMBER ONE, TO REMEMBER THAT those patients who are being treated with
steroids which might INFLUENCE

THE DURATION OF THE VIRAL

SHEDDING, AND ALSO, WE DON\'T

KNOW WHAT THAT MEANS FOR

TRANSMISSION.

THAT\'S ONE OF THE CRITICALLY

IMPORTANT EPIDEMIOLOGIC

QUESTIONS, WHEN IS THE PERIOD OF

COMMUNICABILITY after the onset of symptoms.

AND I DON\'T THINK WE KNOW THE

answer TO THAT question reliably YET.

OUR GUIDANCE SUGGESTS THAT FOR

PATIENTS WHO MEET THE CASE

DEFINITION OF SARS, ISOLATION

PRECAUTIONS SHOULD BE CONTINUED

FOR A FULL TEN DAYS FOLLOWING

RESOLUTION OF FEVER, PROVIDED that

RESPIRATORY SYMPTOMS ARE ABSENT

OR RESOLVING.

WE HAVE NO DATA SO FAR TO

SUGGEST THAT THAT\'S

INSUFFICIENT.

BUT WE\'RE LOOKING AT THIS VERY

CAREFULLY.

AS SOON AS WE GET MORE DATA THAT

SUGGESTS THAT IT\'S NOT, WE WILL

COMMUNICATE THAT VERY RAPIDLY.

RIGHT NOW, WE\'RE SITTING TIGHT

WITH THAT RECOMMENDATION.

AND FOLLOWING VERY CLOSELY THE

SITUATION.

\>\> Kysa: OKAY.

AND PATTY OUT OF NEW YORK CITY

WANTS TO KNOW, IS THERE A

DIFFERENCE BETWEEN TREATMENT

PROTOCOL BETWEEN THE UNITED

STATES, CHINA, AND HONG KONG?

\>\> WE DON\'T HAVE A LOT OF DATA

WITH WHAT TREATMENT REGIMENS ARE

BEING USED IN CHINA.

IN HONG KONG THEY WIDELY

PUBLISHED THEIR USE OF A

COMBINATION OF RIBAVIRIN, PLUS

STEROIDS.

There are SOME ANECDOTAL REPORTS FROM THAT

THAT THERE MIGHT BE SOME BENEFIT

TO PATIENTS.

BUT AGAIN, WE THINK THAT THOSE

DATA ARE DIFFICULT TO INTERPRET

IN THE ABSENCE OF A CONTROLLED

TRIAL.

IN THE UNITED STATES, OF COURSE,

WE\'VE HAD VERY FEW PATIENTS IN

GENERAL,

RIBAVIRIN and/or steroids have NOT BEEN USED

WIDELY in our patients.

\>\> Kysa: AND JUST TO LET

EVERYONE KNOW, WE ARE GOING TO

RUN JUST A LITTLE LONG TODAY,

BECAUSE WE HAVE BEEN GETTING SO

MANY QUESTIONS IN from VIEWERS TODAY.

SO WE\'LL CONTINUE RIGHT ALONG.

THIS ONE IS OUT OF FLORIDA.

WHEN IS A PERSON WITH SARS

CONSIDERED NO LONGER \-- NO

LONGER CONSIDERED INFECTIOUS?

\>\> I THINK AS I SAID BEFORE, OUR

POLICY IS THAT FOR THOSE THAT

MEET THE CASE DEFINITION, FOR

TEN DAYS FOLLOWING RESOLUTION OF

FEVER, PRESUMING THAT THE

RESPIRATORY SYMPTOMS ARE either ABSENT

OR RESOLVING.

\>\> Kysa: AND THIS QUESTION OUT

OF ARIZONA, IN THE UNITED STATES

DOES CDC RECOMMEND TRIAGE IN THE

E.R. AND URGENT CARE CENTERS FOR

ITS SUSPECTED SARS PATIENTS?

\>\> YES, WE DO RECOMMEND TRIAGE.

IT\'S PART OF AN OUTPATIENT

PROCEDURE AN E.R. PROCEDURE TO

ASSESS THE STATUS OF PATIENTS

WHO ARE PRESENTING WITH

SYMPTOMS.

AND WE ENCOURAGE SOME KIND OF

VERBAL SIGNAGE TO ALERT PATIENTS

THAT THEY SHOULD REPORT SIGNS

AND SYMPTOMS.

AND THAT THEY USE A MASK IF THEY

DO HAVE RESPIRATORY SYMPTOMS,

AND TO SEGREGATE THOSE PATIENTS

INTO AN AREA WHERE THEY WILL NOT

HAVE CONTACT WITH OTHERS WHO MAY

BE IN THAT AREA.

BUT YES, INDEED, TRIAGE SHOULD

OCCUR IN THOSE SETTINGS.

\>\> Kysa: AND A VIEWER OUT OF

CALIFORNIA WANTS TO KNOW, ARE

THE ALCOHOL GELS AS EFFECTIVE AS

USING, MS. CHIARELLO, SOAP AND

WATER?

\>\> As far as we know, THE ALCOHOL GELS SHOULD BE equally AS

EFFECTIVE AS SOAP AND WATER.

\>\> Kysa: WOULD YOU CONSIDER

DENTAL PROCEDURES AS AEROSOL

GENERATING PROCEDURES THAT

WARRANT SPECIAL PRECAUTIONS BY

DENTAL HEALTH CARE WORKERS?

\>\> I THINK IT\'S A GOOD QUESTION.

I THINK THE POTENTIAL is THERE;

HOWEVER, I WOULD BACK UP AND SAY

IT\'S PROBABLY A GOOD IDEA TO

DEFER ANY ELECTIVE DENTAL

TREATMENT IN A PATIENT WHO YOU

SUSPECT HAS SARS.

SO HOPEFULLY THAT SHOULD BE A

PRETTY RARE OCCURRENCE.

\>\> Kysa: THIS IS ANOTHER DENTAL

RELATED QUESTION OUT OF

ILLINOIS.

HAVE DENTAL HEALTH CARE WORKERS

EXPERIENCED SARS INFECTION

FOLLOWING DENTAL PROCEDURES ON

SARS INFECTED PEOPLE?

\>\> I\'M NOT AWARE OF ANY

INFECTIONS IN DENTAL WORKERS.

\>\> Kysa: AND NOW, DONNA OUT OF

MINNESOTA WANTS TO KNOW, I HEARD

ON NPR THAT IN CHINA, THEY HAVE

IDENTIFIED THE VIRUS IN FEces.

CAN THE panel comment on public health measures to contain THIS TYPE OF

TRANSMISSION?'s CERTAINLY

IS THE CASE.

DR. JERNIGAN SHOWED INDICATION

THAT THE VIRUS WAS PRESENT IN

BOTH feces AND URINE.

CLEARLY THAT MEANS THAT ADEQUATE

HYGIENE IS IMPORTANT TO MAKE

SURE THAT THAT SOURCE OF VIRUS

IS CONTROLLED.

I DON\'T THINK WE HAVE A MAJOR

PROBLEM HERE IN THE UNITED

STATES.

BUT IN SOME DEVELOPING PARTS OF

THE WORLD, THAT MAY IN FACT BE A

SOURCE OF GREAT CONCERN.

\>\> Kysa: LOOKS LIKE THIS ONE\'S

OUT OF WEST VIRGINIA.

IS IT OKAY TO GIVE NEBULIZER

TREATMENTS AND WHAT MEDICATION

SHOULD BE USED IN THE

NEBULIZER?

\>\> WE\'RE CURRENTLY RECOMMENDING

AGAINST nebulization UNLESS IT\'S MEDICALLY

NECESSARY.

MAYBE DR. JERNIGAN HAS A COMMENT

IN TERMS OF MEDICATION.

BUT IN TERMS OF THE PROCEDURE,

WE WOULD DISCOURAGE IT UNLESS IT

WAS MEDICALLY NECESSARY.

IF IT IS MEDICALLY NECESSARY, TO

DO IT IN AN ENVIRONMENT, in a

PROTECTED ENVIRONMENT, a NEGATIVE

PRESSURE ROOM WOULD BE IDEAL

WITH HEALTH CARE PERSONNEL

APPROPRIATELY GARBED IN GOWN AND

GLOVES AND RESPIRATORY

PROTECTION AND GOGGLES AS WELL.

\>\> Kysa: DR. JERNIGAN, THIS

PERSON SAYS THAT YOU STATED THAT

ANY DETERGENT SHOULD BE

SUFFICIENT TO KILL THE ORGANISM.

WAS THIS A CORRECT STATEMENT, OR

DID YOU MEAN ANY DISINFECTANT?

\>\> WELL, WE THINK THAT BEING A

lipid envelope VIRUS, WE HAVE NO

REASON TO SUSPECT HOUSEHOLD

DETERGENTS SHOULDN\'T BE

EFFECTIVE IN CONTROLLING THIS

VIRUS.

AND I ALSO SAID DISINFECTANTS

AS WELL.

WE have HEARD some REPORTS FROM SOME LABS

AROUND THE WORLD THAT have QUESTIONED

THAT.

WE THINK THE DATA ARE

SURPRISING.

AND WE THINK THEY NEED TO BE

CONFIRMED IN OTHER EXPERIMENTS.

AND WE ARE IN THE PROCESS OF

PURSUING SOME OF THOSE ANSWERS.

I DON\'T KNOW IF JIM OR, DEAN, IF

YOU HAVE ANY OTHER THOUGHTS ON

THAT.

\>\> WELL, I THINK THE CONSENSUS

IS THAT, YOU KNOW, ESTABLISHED

DISINFECTANTS WILL likely WORK WELL

WITH THIS PARTICULAR VIRUS.

BUT again, THOSE STUDIES ARE BEING DONE

AND WE\'LL KNOW more IN THE NEAR

FUTURE.

\>\> Kysa: It's such a new disease and there's so much to learn. The
next question is out of NEW YORK.

DO PEDIATRIC PATIENTS HAVE A

DIFFERENT TEMPERATURE THRESHOLD

THAN 100.4?

AND THEN THE SECOND QUESTION IS,

Is TYLENOL PREFERRED OVER

ASPIRIN BECAUSE OF ASPIRIN\'S

POTENTIAL ACTION ON P-38?

\>\> SO FAR WE HAVE NO DISTINCTION

BETWEEN THE TEMPERATURE

THRESHOLD FOR ADULTS AND

CHILDREN WITH REGARD TO our

CASE DEFINITION.

I\'M NOT A PEDIATRICIAN.

AND I THINK IN GENERAL WE PREFER

TYLENOL OVER ASPIRIN FOR FEBRILE

IN THAT AGE GROUP. But

I\'M A LITTLE FAR AFIELD FROM MY

AREA OF EXPERTISE IN THAT

REGARD.

\>\> Kysa: ALL RIGHT.

ALSO FROM NEW YORK, ANY EVIDENCE

THAT INFECTION WITH MILDER

CORONAVIRUS CONFERS IMMUNITY FOR

SARS?

\>\> I THINK, AGAIN, WE DON\'T HAVE

AN ANSWER FOR THAT.

BUT I THINK THE EVIDENCE

SUGGESTS THAT THE SEROLOGICAL

EVIDENCE SUGGESTS THAT THERE\'S

NO ANTIBODIES TO SARS.

WE\'RE CLEARLY, MOST OF US,

INFECTED WITH THE HUMAN

CORONAVIRUSES, HENCE, IT\'S

LIKELY THAT THERE WOULD BE NO

PROTECTION FROM HUMAN

CORONAVIRUSES FOR THE SARS

AGENT.

\>\> Kysa: OUT OF SOUTH DAKOTA, I

HAVE UNDERSTOOD THE INFLUENZA

VACCINES ARE MADE IN RESPONSE TO

THE PATTERN OF INFLUENZA IN

SOUTHEAST ASIA IN THE SPRING.

WILL THIS HAVE ANY BEARING ON

CORONAVIRUS?

COULD WE EXPECT YOU, AS THE

UNITED STATES \-- A U.S. SPIKE IN

U.S. INCIDENCE NEXT FALL?

\>\> EVERY YEAR THE CDC

PARTICIPATES IN A GLOBAL NETWORK

OF LABORATORIES THAT MONITOR

TRANSMISSION OF INFLUENZA AROUND

THE WORLD.

AND TWICE A YEAR, CDC AND OTHER

EXPERTS GET TOGETHER AT THE

WORLD HEALTH ORGANIZATION AND

DECIDE UPON THE COMPOSITION OF

THAT YEAR\'S INFLUENZA VACCINE.

IN SEPTEMBER, WE\'LL MEET TO

DISCUSS THE VACCINE FOR THE

SOUTHERN HEMISPHERE, AND IN

FEBRUARY WE WILL FOR THE

NORTHERN HEMISPHERE.

I DON\'T THINK THAT THERE\'S ANY

REASON TO SUGGEST THAT THE

INCIDENCE OF INFLUENZA WILL BE

AFFECTED ONE WAY OR ANOTHER BY

THE INCIDENCE OF THE SARS

OUTBREAK THAT WE\'RE CURRENTLY

EXPERIENCING.

\>\> Kysa: DR. LE DUC, THIS IS AN

INTERESTING QUESTION.

ILLINOIS.

WHAT IS THE MODE OF DEATH FROM

SARS, RESPIRATORY FAILURE,

MULTI-ORGAN FAILURE, second-degree

INFECTION, OR OTHER?

\>\> I THINK THAT MOST PATIENTS

DIE OF ARDS.

BUT PERHAPS DR. JERNIGAN CAN

GIVE US MORE a little more DETAIL.

\>\> I THINK THAT\'S RIGHT.

OF COURSE, WE HAVEN\'T HAD ANY

DIRECT EXPERIENCE with DEATHs

FROM SARS HERE IN THE UNITED

STATES.

BUT FROM COMMUNICATION WITH OUR

INTERNATIONAL PARTNERS AND FROM

WHAT WE\'VE SEEN IN THE

LITERATURE, IT WOULD APPEAR THAT

THE MECHANISM IS BASICALLY

DIFFICULTY OXYGENATING THESE

PATIENTS, AND ARDS AND SEVERE

RESPIRATORY FAILURE.

MULTI-ORGAN SYSTEM FAILURE HAS

BEEN REPORTED IN A FEW PATIENTS

but not all, AND I THINK THE DIFFICULTY

OXYGENATING PATIENTS HAS BEEN

THE MAJOR MODE OF DEATH.

\>\> Kysa: OUT OF ALASKA, THE

QUESTION IS, IS A NASAL WASH

CONSIDERED AN AEROSOL GENERATING

PROCEDURE?

\>\> AGAIN, I THINK SOME JUDGMENT

NEEDS TO BE EXERCISED.

THAT\'S NOT CURRENTLY INCLUDED IN

OUR SORT OF LIST OF WHAT WE

CONSIDER AEROSOL GENERATING

PROCEDURES.

BUT, YOU KNOW, AFTER WE GET MORE

INFORMATION, WE MAY NEED TO

RECONSIDER THAT.

BUT CURRENTLY, NOT.

\>\> LET ME JUST ADD THAT, NASAL

WASHES HAVE BEEN A SOURCE OF

VIRUS IN THE some of the SPECIMENS WE\'RE

TESTING.

SO IF A CLINICIAN SUSPECTS A

PATIENT WITH SARS and IS TAKING A

NASAL WASH, CLEARLY THE PERSONAL

PROTECTIVE MEASURES WE\'VE BEEN

DISCUSSING SHOULD BE IN PLACE.

\>\> Kysa: THIS CALLER WANTS TO

KNOW, GRADUATION IS NEAR.

WHAT ABOUT VISITORS FROM CHINA

OR OTHER AFFECTED AREAS?

WHAT ABOUT THEM?

\>\> AGAIN, WE HAVE GUIDANCE ON

OUR WEB SITE ON WHAT SHOULD BE

DONE.

I THINK IT\'S IMPORTANT THAT A

PERSON WHO\'S VISITING FROM AN

EXPOSED \-- FROM AN AREA

ASSOCIATED WITH SARS

TRANSMISSION SHOULD MONITOR

THEMSELVES VERY CLOSELY FOR A

PERIOD OF TEN DAYS AFTER LEAVING

THE EXPOSED AREA, MEASURE THEIR

TEMPERATURE TWICE A DAY,

AND AT THE FIRST SIGN OF ANY

FEVER OR RESPIRATORY SYMPTOM OR

ILLNESS, SHOULD CONTACT A HEALTH

CARE PROVIDER,

AGAIN, EMPHASIZING THAT IF

THEY\'RE PRESENTING FOR

EVALUATION, THEY SHOULD NOTIFY

THE HEALTH CARE PROVIDER AHEAD

OF TIME, IN ADVANCE, THAT YOU\'RE

A PERSON WHO MAY HAVE BEEN INTO

A SARS-EXPOSED AREA AND YOU HAVE

A RESPIRATORY ILLNESS OR FEVER,

SO THE PREPARATIONS CAN BE MADE

TO \-- FOR ISOLATION WHEN ONE

PRESENTS TO THE HEALTH CARE

SETTING.

\>\> Kysa: THIS QUESTION OUT OF

WISCONSIN, ALSO RELATED.

IT SAYS, WE TALK ABOUT ASIA, AS

CHINA, TAIWAN, SINGAPORE,

ETCETERA.

IS THERE EVIDENCE IN KOREA

AND JAPAN, AND WHAT ARE THE

PRECAUTIONS THAT U.S. TRAVELERS

SHOULD TAKE WHEN TRAVELING TO

THESE DIFFERENT AREAS?

\>\> I THINK THE WORLD HEALTH

ORGANIZATION HAS A VERY ACCURATE

AND UP-TO-DATE WEB SITE THAT

DOCUMENTS THE PRESENCE OF CASES

AROUND THE WORLD.

AND TRAVELERS MAY WISH TO CHECK

THAT WEB SITE.

AND I THINK WE\'LL GIVE THAT TO

YOU BEFORE THE END OF THE

DISCUSSION.

\>\> Kysa: I\'LL JUST GIVE IT OUT

QUICKLY RIGHT NOW.

IT IS WWW..WHO.INT, AND then the web address for CDC is

WWW.CDC.GOV.

NEXT QUESTION OUT OF HONOLULU,

HAWAII, IS IT NECESSARY TO PUT

SUSPECTED SARS PATIENT IN A

NEGATIVE AIR PRESSURE ROOM?

\>\> THE ANSWER IS YES.

IF THE PATIENT NEEDS \-- REQUIRES

HOSPITALIZATION, THEN A NEGATIVE

PRESSURE ROOM IS INDICATED UNTIL

THAT PATIENT \-- THE DIAGNOSIS OF

SARS CAN BE RULED OUT.

WE RECOMMEND AIRBORNE

PRECAUTIONS FOR ANYONE WITH A

SUSPECT SARS.

AND SO IF THEY\'RE HOSPITALIZED,

INDEED, THEY WOULD BE PUT INTO

THAT KIND OF ENVIRONMENT.

\>\> Kysa: AND I THINK WE\'VE

ALREADY KIND OF TOUCHED ON THIS.

OUT OF CALIFORNIA.

IT SAYS, CORONAVIRUS, OR IS

CORONAVIRUS, OR HAS IT BEEN

DETECTED IN STOOL and URINE FROM

SARS PATIENTS? (yes)

\>\> Kysa: OUT OF FLORIDA, Acute phase SERUM

IS BEING USED FOR SARS LAB

DIAGNOSIS.

WHAT OTHER \-- WHAT ELSE IS

NEEDED TO RULE OUT EXPOSURE TO

OTHER CORONAVIRUSES?

\>\> I THINK THE QUESTION IS, WHAT

TITER.

BECAUSE SARS coronavirus is SO RARE IN this

POPULATION NOW, in our population now, ANY DETECTABLE

ANTIBODY WOULD BE CONSIDERED A

POSITIVE.

SO YOU DON\'T HAVE TO MEASURE AN

AMOUNT ABOVE A CERTAIN BASELINE

LEVEL AT THIS POINT.

\>\> Kysa: OKAY.

ALL RIGHTY.

DO WE HAVE SOME MORE QUESTIONS?

I HAVE A WHOLE STACK HERE.

AGAIN, I WANT TO GIVE OUT THE

WEB SITES FOR THOSE OF YOU

WATCHING.

IT\'S WWW.WHO.INT FOR THE WORLD

HEALTH ORGANIZATION.

AND THEN THE WEB ADDRESS FOR CDC

IS WWW.CDC.GOV.

QUESTION OUT OF VIRGINIA, IS

SARS BEING LOOKED AT AS A

POTENTIAL BIOTERRORIST AGENT?

\>\> THAT\'S A VERY GOOD QUESTION.

AND CERTAINLY WAS IN OUR

THINKING AS THIS OUTBREAK

ORIGINATED

AND WE LEARNED MORE AND MORE

ABOUT IT.

THE INFORMATION THAT DR. ERDMAN

HAS PRESENTED ABOUT THE VERY,

VERY UNIQUE SEQUENCE OF THIS

VIRUS WOULD LEAD US TO BELIEVE

THAT it IS A NATURALLY OCCURRING

VIRUS UNLIKE ANY OTHER VIRUS

THAT\'S KNOWN TO SCIENCE, AND

CONSEQUENTLY, ALMOST CERTAINLY

NOT MAN-MADE.

\>\> Kysa: NEXT QUESTION.

HOW EFFECTIVE ARE CORONAVIRUS

VACCINES IN ANIMALS?

\>\> I\'M NOT FAMILIAR WITH THE

VETERINARY WORLD.

THERE ARE NO CORONAVIRUS

VACCINES FOR HUMANS, BECAUSE, they're very mild infections.

CERTAINLY THERE\'S A LOT OF

ONGOING RESEARCH TO LOOK AT THE

POTENTIAL FOR VACCINES FOR THIS

AGENT IN THE FUTURE.

\>\> Kysa: AND THEN OUT OF

MARYLAND, THE PERSON WANTS TO

KNOW, HOW DO THE CASE FATALITY

RATES FOR SARS COMPARE TO THAT

OF INFLUENZA?

\>\> THE CASE FATALITY RATE FOR

SARS SEEMS TO BE CREEPING UP AS

WE LEARN MORE ABOUT THE DISEASE,

WE HAVE MORE DATA TO WORK FROM.

THE WORLD HEALTH ORGANIZATION

HAS RECENTLY PUBLISHED SOME

ESTIMATES OF CASE FATALITY

RATIO THAT SUGGESTED THOSE IN

THE OLDER AGE GROUPS, ABOVE 65,

ARE AT ESPECIALLY HIGH RISK OF

DYING FROM THE INFECTION. And

CONVERSELY, THOSE IN THE VERY

YOUNG AGE GROUPS ARE, WE\'VE SEEN

MORTALITY VERY, VERY RARELY.

AND IT\'S A GRADATION ON UP.

I THINK IN GENERAL THE MORTALITY

RATE IN INFLUENZA IS LESS THAN

WHAT WE\'RE NOW ESTIMATING

OVERALL FOR SARS INFECTIONS.

\>\> Kysa: AND THEN A QUESTION OUT

OF KENTUCKY.

WHAT ARE TRUE SPECIAL

PRECAUTIONS FOR HANDLING OF

TISSUE SPECIMENS FROM SUSPECTED

SARS PATIENTS?

\>\> AGAIN, AS WE MENTIONED BEFORE

I WOULD ENCOURAGE YOU TO CHECK

THE WEB SITE.

THERE\'S A SPECIFIC GUIDANCE

DOCUMENT ON HANDLING OF

LABORATORY SPECIMENS.

IT\'S QUITE DETAILED.

\>\> Kysa: WE\'RE RUNNING OUT OF

QUESTIONS.

I THINK THINGS ARE KIND OF

SLOWING DOWN.

AND UNFORTUNATELY, THAT\'S ALL

THE TIME WE HAVE FOR YOUR

QUESTIONS.

IF YOU HAVE ANY ADDITIONAL

QUESTIONS THAT YOU\'D LIKE TO

HAVE ANSWERED, PLEASE USE THE

CDC CLINICIANS INFORMATION LINE,

AND THAT NUMBER TO CALL IS

1-877-554-4625.

AGAIN, THAT NUMBER,

1-877-554-4625.

FOR OTHER QUESTIONS, REMEMBER TO

VISIT THE CDC AND WORLD

HEALTH ORGANIZATION WEB SITEs for the very latest information on SARS.

WE\'LL REPEAT THOSE WEB

ADDRESSES.

FIRST THE WORLD HEALTH

ORGANIZATION, WWW.WHO.INT.

AND THEN HERE AT CDC, WEB SITE

IS WWW.CDC.GOV.

PARTICIPANTS OF THIS BROADCAST

ARE ENCOURAGED BUT NOT REQUIRED

TO REGISTER AND EVALUATE THE

PROGRAM ON THE CDC TRAINING AND

CONTINUING EDUCATION ONLINE

SYSTEM.

AND THAT ADDRESS IS

WWW.PHPPO.CDC.GOV/PHTNONLINE.

PARTICIPANT REGISTRATION AND

EVALUATION WILL BEGIN MAY 8th,

2003, AND END ON JUNE THE 8th,

2003\.

AND HERE ARE THE COURSE NUMBERS

THAT YOU\'LL NEED.

THE NUMBER FOR THE SATELLITE

BROADCAST.

SB 0130.

AND THEN FOR THE WEB CAST, THE

NUMBER, WC 0030.

QUESTIONS

ABOUT REGISTRATION SHOULD BE

DIRECTED TO 800-41-TRAIN, OR

404-639-1292.

OR E-MAIL CE AT CDC.GOV.

WHEN E-MAILING A REQUEST, PLEASE

INDICATE SARS 2, THAT IS THE

NUMBER 2, IN THE SUBJECT LINE.

AND BEFORE WE WRAP UP, I WANT TO

MAKE SURE THAT CLINICIANS WHO

WATCH OUR PROGRAM ARE AWARE OF

THE CLINICIANS\' REGISTRY.

CLINICIANS WHO REGISTER AT THIS

SITE WILL RECEIVE ALERTS AND

UPDATES ON PUBLIC HEALTH THREATS

AND INFORMATION ON CDC SPONSORED

TRAINING.

TO JOIN THIS REGISTRY YOU CAN

VISIT ANOTHER WEB SITE,

WWW.BT.CDC.GOV/CLINREG.

WE\'D LIKE TO INVITE YOU TO JOIN

US FOR OUR NEXT BROADCAST, WHICH

IS COMMUNITY PREPAREDNESS FOR

SEVERE ACUTE RESPIRATORY

SYNDROME \-- SARS.

THAT\'S GOING TO BE ON TUESDAY,

MAY 20th FROM 1:00 UNTIL

2:30 P.M.

I\'M KYSA DANIELS.

IT CERTAINLY HAS BEEN MY

PLEASURE BEING YOUR MODERATOR

FOR THIS BROADCAST.

THANK YOU AGAIN TO DR. JERNIGAN,

TO LINDA CHIARELLO, TO

DR. ERDMAN, AND DR. JIM LE DUC.

WE APPRECIATE YOUR EXPERTISE AND

TIME.

GOOD-BYE from ALL OF US FROM US

HERE AT THE CENTERS FOR DISEASE

CONTROL AND PREVENTION HERE IN

ATLANTA.

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