**DOE - SEVERE ACUTE RESPIRATORY SYNDROME (SARS) UPDATE -- June 12,
2003**

I have been monitoring the SARS situation and provide the following
information that is current as of **Wednesday, June 12, 2003**, 0800
hours, EDT. Information presented is routinely taken from the Centers
for Disease Control and Prevention (CDC),
<http://www.cdc.gov/ncidod/sars/index.htm>, The World Health
Organization (WHO), <http://www.who.int/csr/sars/en/>, the Department of
Defense Global Emerging Infections Surveillance and Response System
site, (DoD-GEIS)-<http://www.geis.ha.osd.mil/>, and other creditable
sources. You will find the most current information in this document
up-front.

**WHO - Update on cases and countries**\
As of **11 June** 2003, 14:00 GMT+2, a cumulative total of 8435 probable
SARS cases with 789 deaths (9.35% mortality, see charts and map, pp 3-4)
has been reported from 29 countries. This represents an increase of 5
new cases since WHO's last update on 10 June. **No new deaths were
reported.**

**Recent news**

On 10 June, the **CDC updated its Questions and Answers: Travel and
Quarantine** -\
<http://www.cdc.gov/ncidod/sars/qa/travel.htm>. On June 4, CDC
downgraded the traveler notification for **Hong Kong from a travel
advisory to a travel alert**, meaning that ***there is no recommendation
against nonessential travel to the area*** -
<http://www.cdc.gov/ncidod/sars/travel_alertadvisory.htm>***.* On 2
June,** WHO added **Inner Mongolia to its list of areas with recent
local transmission, for which, travellers should consider postponing all
but essential travel.** Effective **Saturday 31 May**, **Singapore was
removed** from the WHO list of areas with recent local transmission of
SARS. On **23 May 2003,** the **CDC** reinstated their **Travel Alert
for Toronto, Ontario, Canada** -
<http://www.cdc.gov/travel/other/sars_can.htm>. As of **21 May**,
**WHO** has removed the **Philippines** from its list of areas with
recent local transmission and has added **Taiwan**.

## WHO Update 78 -- Situation in Toronto

## 11 June 2003 - [**http://www.who.int/csr/don/2003_06_11a/en/**](http://www.who.int/csr/don/2003_06_02a/en/)

WHO is deeply concerned by the resurgence of SARS cases in Toronto,
reported to WHO on 22 May, and is following the situation closely.
Toronto, which had been removed from the list of areas with recent local
transmission on 14 May, was again added to the list on 26 May following
evidence that more than one generation of new cases had occurred. Since
the disease first resurged in Toronto, over 90 new probable cases have
been reported.

Health authorities in Toronto are again on high alert, and are treating
all hospital-associated clusters of patients with fever or respiratory
symptoms as possible SARS cases until proven otherwise. Possible cases
are immediately isolated. All contacts are being traced and, when
warranted, placed in home quarantine. Infection control measures are
being followed in all affected facilities. WHO welcomes these
precautionary measures.

Canadian authorities have most recently reported a possible cluster of
SARS patients in a hospital east of Toronto. Although no clear
epidemiological link has been established that could explain this new
cluster, officials have adopted a cautious approach. Over the last 3
days, 15 dialysis patients at the Lakeridge Health Centre in Whitby
exhibited respiratory and febrile illnesses. After clinical review and
laboratory investigations to detect other causative agents, around half
of these patients have now been excluded from consideration as possible
SARS cases. The remaining patients are being closely monitored.

These and other investigations are ongoing and many questions remain to
be answered before firm conclusions can be reached.

WHO is also awaiting further information on cases in other countries
that may have been exported from Toronto. WHO is not yet convinced that
such cases have been conclusively documented.

One of the most dangerous stages in the evolution of any outbreak, and
most especially one caused by a new and poorly understood disease,
occurs when cases begin to decline and previous levels of high alert and
precautionary measures likewise begin to level off. Much about the
clinical behaviour of SARS and its mode of transmission requires further
research. Until knowledge improves, precautionary measures such as those
being followed in Toronto are the best approach from a public health
perspective.

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**WHO - SARS Travel Recommendations Summary Table**

**11 June 2003** -
[http://www.who.int/csr/sars/travel/2003_05_30/en/](http://www.who.int/csr/sars/travel/2003_05_27/en/)

**This table, updated daily, indicates those areas with recent local
transmission of SARS for which WHO has issued recommendations pertaining
to international travel.** All international travellers should be aware
of the main features of SARS and the areas of the world where local
transmission has been reported. This table summarizes those areas of the
world for which further specific measures have been recommended.
[Summary of WHO measures related to international
travel](http://www.who.int/csr/sars/travelupdate/en/)

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| |   ----                                                           |  |
| | ------- ---------------- ------------------ -------------------- |  |
| |   **Country   **Area  **       **Exit screening   **Traveller to |  |
| |    **                                                            |  |
| |                           for international  consider postponing |  |
| |                                                                  |  |
| |                             travellers         all but essential |  |
| |                                                                  |  |
| |                            departing the area travel to the area |  |
| |                                 **                 **            |  |
| |                                                                  |  |
| |   **Canada    **Toronto  **    **YES  **          **NO  **       |  |
| |    **                                                            |  |
| |                                                                  |  |
| |   **China  ** **Beijing  **    **YES  **          **YES  **      |  |
| |                                                                  |  |
| |   **China  ** **Guangdong  **  **YES  **          **NO  **       |  |
| |                                                                  |  |
| |   **China  ** **Hebei  **      **YES  **          **YES  **      |  |
| |                                                                  |  |
| |   **China  ** **Hong Kong      **YES  **          **NO  **       |  |
| |               Special                                            |  |
| |               Administrative                                     |  |
| |               Region of China                                    |  |
| |                **                                                |  |
| |                                                                  |  |
| |   **China  ** **Inner Mongolia **YES  **          **YES  **      |  |
| |                **                                                |  |
| |                                                                  |  |
| |   **China  ** **Jilin  **      **YES  **          **NO  **       |  |
| |                                                                  |  |
| |   **China  ** **Shanxi  **     **YES  **          **YES  **      |  |
| |                                                                  |  |
| |   **China  ** **Tianjin  **    **YES  **          **YES  **      |  |
| |                                                                  |  |
| |   **China  ** **Taiwan  **     **YES  **          **YES  **      |  |
| |   ----                                                           |  |
| | ------- ---------------- ------------------ -------------------- |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

[http://www.who.int/csr/sars/map2003_06_11.jpg](http://www.who.int/csr/sars/map2003_06_02.gif)

![](media/image1.png){width="6.760416666666667in"
height="4.200694444444444in"}

<http://www.who.int/csr/sars/map2003_06_11.jpg>

![](media/image2.wmf){width="6.875in" height="4.125in"}

![](media/image3.wmf){width="6.854166666666667in"
height="4.386805555555555in"}

**CDC FACT SHEET - Basic Information About SARS**\
June 4, 2003 - <http://www.cdc.gov/ncidod/sars/factsheet.htm>

![](media/image4.png){width="0.5416666666666666in"
height="0.14583333333333334in"}**\|
[Español](http://www.cdc.gov/ncidod/sars/espanol/hoja-informativa.htm)
\| [Français](http://www.cdc.gov/ncidod/sars/pdf/factsheetfrench.pdf)
\|** ![](media/image5.png){width="0.59375in"
height="0.10416666666666667in"}

[Download PDF version formatted for
print](http://www.cdc.gov/ncidod/sars/pdf/factsheet.pdf)
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**A new disease called SARS**\
Severe acute respiratory syndrome (SARS) is a respiratory illness that
has recently been reported in Asia, North America, and Europe. This fact
sheet provides basic information about the disease and what is being
done to combat its spread. To find out more about SARS, go to
[www.cdc.gov/ncidod/sars/](http://www.cdc.gov/ncidod/sars/) and
[www.who.int/csr/sars/en/](http://www.who.int/csr/sars/en/) . The Web
sites are updated daily.

**Symptoms of SARS**\
In general, SARS begins with a fever greater than 100.4°F \[\>38.0°C\].
Other symptoms may include headache, an overall feeling of discomfort,
and body aches. Some people also experience mild respiratory symptoms.
After 2 to 7 days, SARS patients may develop a dry cough and have
trouble breathing.

**How SARS spreads**\
The primary way that SARS appears to spread is by close person-to-person
contact. Most cases of SARS have involved people who cared for or lived
with someone with SARS, or had direct contact with infectious material
(for example, respiratory secretions) from a person who has SARS.
Potential ways in which SARS can be spread include touching the skin of
other people or objects that are contaminated with infectious droplets
and then touching your eye(s), nose, or mouth. This can happen when
someone who is sick with SARS coughs or sneezes droplets onto
themselves, other people, or nearby surfaces. It also is possible that
SARS can be spread more broadly through the air or by other ways that
are currently not known.

**Who is at risk for SARS**\
Most of the U.S. cases of SARS have occurred among travelers returning
to the United States from other parts of the world with SARS. There have
been very few cases as a result of spread to close contacts such as
family members and health care workers. Currently, there is no evidence
that SARS is spreading more widely in the community in the United
States.

**Possible cause of SARS**\
Scientists at CDC and other laboratories have detected a previously
unrecognized coronavirus in patients with SARS. The new coronavirus is
the leading hypothesis for the cause of SARS.

######### What CDC is doing about SARS

CDC is working closely with the World Health Organization (WHO) and
other partners in a global effort to address the SARS outbreak. For its
part, CDC has taken the following actions:

-   Activated its Emergency Operations Center to provide round-the-clock
    coordination and response.

-   Committed more than 700 medical experts and support staff to work on
    the SARS response.

-   Deployed medical officers, epidemiologists, and other specialists to
    assist with on-site investigations around the world.

-   Provided ongoing assistance to state and local health departments in
    investigating possible cases of SARS in the United States.

-   Conducted extensive laboratory testing of clinical specimens from
    SARS patients to identify the cause of the disease.

-   Initiated a system for distributing health alert notices to
    travelers who may have been exposed to cases of SARS.

**CDC RECOMMENDATIONS**\
CDC has issued recommendations and guidelines for people who may be
affected by this outbreak.

**For individuals considering travel to areas with SARS:**\
CDC has issued two types of notices to travelers: advisories and alerts.
A ***travel advisory*** recommends that nonessential travel be deferred;
a ***travel alert*** does not advise against travel, but informs
travelers of a health concern and provides advice about specific
precautions. CDC updates information on its website on the travel status
of other [areas with SARS](http://www.cdc.gov/ncidod/sars/travel.htm) as
the situation evolves.

**For individuals who must travel to an area with SARS:**\
CDC advises that travelers in an area with SARS should wash their hands
frequently to protect against SARS infection. In addition, CDC advises
that travelers may wish to avoid close contact with large numbers of
people as much as possible to minimize the possibility of infection. CDC
does not recommend the routine use of masks or other personal protective
equipment while in public areas. For more information, read the Interim
Guidelines about Severe Acute Respiratory Syndrome (SARS) for [Persons
Traveling to Areas with
SARS.](http://www.cdc.gov/ncidod/sars/travel_advice.htm)

**For individuals who think they might have SARS:**\
People with symptoms of SARS (fever greater than 100.4°F \[\>38.0°C\]
accompanied by a cough and/or difficulty breathing) should consult a
health-care provider. To help the health-care provider make a diagnosis,
tell them about any recent travel to places where SARS has been reported
or whether there was contact with someone who had these symptoms.

**For family members caring for someone with SARS:**\
CDC has developed [interim infection control recommendations for
patients with suspected SARS in the
household](http://www.cdc.gov/ncidod/sars/ic-closecontacts.htm). These
basic precautions should be followed for 10 days after respiratory
symptoms and fever are gone. During that time, SARS patients are asked
to limit interactions outside the home (not go to work, school, or other
public areas).

**For health-care workers:**\
Transmission of SARS to health-care workers appears to have occurred
after close contact with sick people before recommended infection
control precautions were put into use. CDC has issued [interim infection
control recommendations for health-care
settings](http://www.cdc.gov/ncidod/sars/infectioncontrol.htm) as well
as for the [management of exposures to SARS in health-care and other
institutional
settings](http://www.cdc.gov/ncidod/sars/exposureguidance.htm).

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

**CDC - Frequently Asked Questions and Answers on SARS**\
June 3, 2003 - <http://www.cdc.gov/ncidod/sars/faq.htm>

**Travel and Quarantine**\
June 10, 2003, 12:00 PM ET -
<http://www.cdc.gov/ncidod/sars/qa/travel.htm>

**GENERAL INFORMATION\
\
THE ILLNESS**

**What is SARS?**\
Severe acute respiratory syndrome (SARS) is a respiratory illness that
has recently been reported in Asia, North America, and Europe. For
additional information, check the World Health Organization\'s (WHO)
SARS Web site or visit other pages on [CDC\'s SARS Web
site](http://www.cdc.gov/ncidod/sars/).

**What are the symptoms and signs of SARS?**\
The illness usually begins with a fever (measured temperature greater
than 100.4°F \[\>38.0°C\]). The fever is sometimes associated with
chills or other symptoms, including headache, general feeling of
discomfort and body aches. Some people also experience mild respiratory
symptoms at the outset.\
After 2 to 7 days, SARS patients may develop a dry, nonproductive cough
that might be accompanied by or progress to the point where insufficient
oxygen is getting to the blood. In 10 percent to 20 percent of cases,
patients will require mechanical ventilation. For more information, see
the [MMWR
dispatch](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5212a5.htm). **If I
were exposed to SARS, how long would it take for me to become sick?**\
The incubation period for SARS is typically 2 to 7 days; however,
isolated reports have suggested an incubation period as long as 10 days.
The illness usually begins with a fever (\>100.4°F \[\>38.0°C\]) (see
signs and symptoms, above).

**Do some people who recover from SARS become sick again or relapse?**\
At this time we do not have a full understanding of the natural course
of illness in persons infected with the SARS coronavirus (SARS Co-V). It
will be important to learn what factors might influence illness
progression and recovery. Such factors could be related to the virus
itself, how the body\'s immune system reacts to the virus, how infection
with the virus is treated, or other possibilities. CDC and other
scientists are trying to learn the answers to these important questions.

**What medical treatment is recommended for patients with SARS?**\
CDC currently recommends that patients with SARS receive the same
treatment that would be used for any patient with serious
community-acquired atypical pneumonia.\
**Is the use of ribavirin (or other antiviral drugs) effective in the
treatment of patients with SARS?**\
At present, the most efficacious treatment regimen, if any, is unknown.
In several locations, therapy has included antivirals such as
oseltamivir or ribavirin. Steroids also have been given orally or
intravenously to patients in combination with ribavirin and other
antimicrobials. In the absence of controlled clinical trials, however,
the efficacy of these regimens remains unknown. Early information from
laboratory experiments suggests that ribavirin does not inhibit virus
growth or cell-to-cell spread of one isolate of the new coronavirus that
was tested. Additional laboratory testing of ribavirin and other
antiviral drugs is being done to see if an effective treatment can be
found.

**The Spread of SARS**\
<http://www.cdc.gov/ncidod/sars/qa/spread.htm>

**How is SARS spread?**\
The primary way that SARS appears to spread is by close person-to-person
contact. Potential ways in which SARS can be spread include touching the
skin of other people or objects that are contaminated with infectious
droplets and then touching your eye(s), nose, or mouth. This can happen
when someone who is sick with SARS coughs or sneezes droplets onto
themselves, other people, or nearby surfaces. It also is possible that
SARS can be spread more broadly through the air or by other ways that
are currently not known.

**What does \"close contact\" mean?**\
The primary way that SARS appears to spread is by close person-to-person
contact. Close contact might occur when between people live together in
the same household or if someone is providing care to a SARS patient.
Examples include kissing or embracing, sharing eating or drinking
utensils, close conversation (within 3 feet), physical examination, and
any other direct physical contact between people. Close contact does not
include activities such as walking by a person or sitting across a
waiting room or office for a brief period of time.

**How can I protect myself against SARS?**\
There are some common-sense measures that you can take to prevent the
spread of SARS that apply to many infectious diseases. The most
important is frequent hand washing with soap and water or use of
alcohol-based hand rubs (See [Guideline for Hand Hygiene in Health-Care
Settings](http://www.cdc.gov/handhygiene/)). In addition, you should
avoid touching your eyes, nose, and mouth with unclean hands and
encourage people around you to cover their nose and mouth with a tissue
when coughing or sneezing.

**How long is a person with SARS infectious to others?**\
Information to date suggests that people are most likely to be
infectious when they have symptoms, such as fever or cough. However, it
is not known how long before or after their symptoms begin that patients
with SARS might be able to transmit the disease to others.

**Who is most at risk of contracting SARS?**\
Most of the U.S. cases of SARS have occurred among travelers returning
to the United States from other parts of the world affected by SARS.
There have been very few cases as a result of spread to close contacts
such as family members and health care workers. Currently, there is no
evidence that SARS is spreading more widely in the community in the
United States.

**Should I wear a surgical mask to protect myself from getting SARS?**\
CDC does not recommend routine use of surgical masks when people are in
public to prevent SARS.

**Are there any times when a surgical mask should be worn to prevent the
spread of SARS?**\
People who have \-- or think they might have \-- SARS should cover their
mouth and nose with a tissue when coughing or sneezing. If possible,
they also should wear a surgical mask during close contact with people
who are not infected (for example, household members) to prevent the
spread of infectious droplets. When a person with SARS is unable to wear
a surgical mask, household members should wear surgical masks when in
close contact with the patient. Surgical masks should fit snugly around
the mouth and nose. Masks are intended for use by one person only and
should not be shared. Masks should be discarded when soiled or moist;
changing masks daily is a good rule of thumb. Hand hygiene should be
performed after handling a soiled mask. For additional information, see
[infection-control precautions for SARS patients and their close
contacts in
households](http://www.cdc.gov/ncidod/sars/ic-closecontacts.htm).

**NEW!** **Should I be concerned about buying items which are made in
countries where SARS has been found?\
**SARS appears to be transmitted mainly by direct contact with
infectious material, including large respiratory droplets spread in the
air when an infected person coughs or sneezes. Touching objects
contaminated with infectious droplets and then touching your eye(s),
nose, or mouth could result in transmission of SARS. Contamination of
environmental surfaces would be a particular concern in health-care
settings and households where patients with SARS would be receiving
care. Furniture, clothing, and other items imported from countries where
SARS has been found would be expected to pose little, if any, risk of
transmission of SARS.

**TESTING FOR SARS**

**Is there a test for SARS?**\
Several laboratory tests can be used to detect the SARS-associated
coronavirus (SARS-CoV). A reverse transcription polymerase chain
reaction (RT-PCR) test can detect SARS-CoV in clinical specimens,
including blood, stool, and nasal secretions. Serologic testing also can
be performed to detect SARS-CoV antibodies produced after infection.
Finally, viral culture has been used to detect SARS-CoV. Currently, all
serologic testing for SARS-CoV in the United States is being done at
CDC. However, CDC has begun to make coronavirus testing materials
available to state health departments and other laboratories.

**What is a PCR test?**\
PCR (or polymerase chain reaction) is a laboratory method for detecting
the genetic material of an infectious disease agent in specimens from
patients. This type of testing has become an essential tool for
detecting infectious disease agents.

**What does serologic testing involve?**\
A serologic test is a laboratory method for detecting the presence
and/or level of antibodies to an infectious agent in serum from a
person. Antibodies are substances made by the body\'s immune system to
fight a specific infection.

**What does viral culture and isolation involve?**

For a viral culture, a small sample of tissue or fluid that may be
infected is placed in a container along with cells in which the virus
can grow. If the virus grows in the culture, it will cause changes in
the cells that can be seen under a microscope.

**CAUSE OF SARS**

**What is the cause of SARS?**\
Scientists at CDC and other laboratories have detected a previously
unrecognized coronavirus in patients with SARS. This new coronavirus is
the leading hypothesis for the cause of SARS.

**What are coronaviruses?**\
Coronaviruses are a group of viruses that have a halo or crown-like
(corona) appearance when viewed under a microscope. These viruses are a
common cause of mild to moderate upper-respiratory illness in humans and
are associated with respiratory, gastrointestinal, liver and neurologic
disease in animals.\
**How long can the SARS coronavirus (SARS Co-V) survive in the
environment? NEW!**\
Preliminary studies in some research laboratories suggest that the virus
may survive in the environment for several days. The length of time that
the virus survives likely depends on a number of factors. These factors
could include the type of material or body fluid containing the virus
and various environmental conditions such as temperature or humidity.
Researchers at CDC and other institutions are designing standardized
experiments to measure how long SARS Co-V can survive in situations that
simulate natural environmental conditions. Data on survival of SARS Co-V
outside of the human body emphasize the importance of frequent
handwashing with soap and water or use of alcohol-based hand rubs if
hands are not visibly dirty. See the \"[Guideline for Hand Hygiene in
Health-Care Settings](http://www.cdc.gov/handhygiene/)\" for more
details on hand hygiene.

**What kills the virus that causes SARS? NEW!**\
Right now, there are no disinfectant products registered by the U.S.
Environmental Protection Agency (EPA) for use on environmental surfaces
that are specifically listed as having the ability to kill the new
coronavirus associated with SARS. However, related viruses that have
similar physical and biochemical properties can be killed with bleach,
ammonia or alcohol, or cleaning agents containing any of these
disinfectants. Cleaning agents should be used according to the
manufacturer\'s instructions.

**If coronaviruses usually cause mild illness in humans, how could this
new coronavirus be responsible for a potentially life-threatening
disease such as SARS?**\
There is not enough information about the new virus to determine the
full range of illness that it might cause. Coronaviruses have
occasionally been linked to pneumonia in humans, especially people with
weakened immune systems. The viruses also can cause severe disease in
animals, including cats, dogs, pigs, mice, and birds.

**Has new information about coronavirus changed the recommendations for
medical treatment for patients with SARS?**\
The possibility that coronavirus is the cause of SARS has not changed
treatment recommendations. The new coronavirus is being tested against
various antiviral drugs to see if an effective treatment can be found.

**What about reports from other laboratories suggesting that the cause
of SARS may be a paramyxovirus?**\
Early on in the SARS investigation, researchers from several
laboratories participating in the WHO network have reported the
identification of a paramyxovirus in clinical specimens from SARS
patients. Later findings indicated that a new coronavirus is the most
likely cause of SARS.

**THE OUTBREAK**

**What is the status of the SARS outbreak in the United States?**\
In the United States, cases of SARS continue to be reported primarily
among people who traveled to affected areas; a small number of other
people have gotten sick after being in close contact with (that is,
having cared for or lived with) a SARS patient while in the United
States. Currently, there is no evidence that SARS is spreading more
widely in the community in the United States.\
\
To minimize the risk for SARS among U.S. residents, the public health
system is taking careful and thorough precautions to stop the spread of
SARS. People who are suspected of having SARS are being isolated from
others and getting care. People arriving from affected parts of the
world (who might have been exposed to SARS) are receiving information
about SARS and instructions on what they should do if they become ill.
SARS patients and their contacts are being monitored to help prevent
spread of the disease.

**What is the status of the SARS outbreak outside the United States?**\
Most cases of SARS have been reported from China. In addition, SARS
cases have been reported from more than 20 other countries. Measures to
control the spread of SARS continue to be used in countries worldwide so
that the outbreak can be contained. Visit [WHO\'s SARS
page](http://www.who.int/csr/sars/en/) for daily updates on case reports
in the United States and other countries.

**What is the difference between a "probable" SARS case and a "suspect"
SARS case?**\
Suspect SARS cases have fever, respiratory illness, and recent travel to
an affected area with community transmission of SARS and/or contact with
a suspect SARS patient. Probable cases meet the criteria for a suspect
case and also have evidence (e.g., chest X-ray) of pneumonia or
respiratory distress syndrome.

CDC Updated Interim U.S. Case Definition of Severe Acute Respiratory
Syndrome (SARS)\
May 23, 2003, 10:00 PM ET -
<http://www.cdc.gov/ncidod/sars/casedefinition.htm>

[**Download PDF version formatted for
print**](http://www.cdc.gov/ncidod/sars/pdf/sars-casedefinition.pdf)
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The previous CDC SARS case definition (published May 20, 2003) has been
updated as follows:

-   In the Epidemiologic Criteria, the last date of illness onset for
    inclusion as reported case for Toronto, Canada is now "ongoing."

**Clinical Criteria**

-   Asymptomatic or mild respiratory illness

-   Moderate respiratory illness

    -   Temperature of \>100.4º F (\>38º C)\*, and

    -   One or more clinical findings of respiratory illness (e.g.,
        cough, shortness of breath, difficulty breathing, or hypoxia).

-   Severe respiratory illness

    -   Temperature of \>100.4º F (\>38º C)\*, and

    -   One or more clinical findings of respiratory illness (e.g.,
        cough, shortness of breath, difficulty breathing, or hypoxia),
        and

        -   radiographic evidence of pneumonia, or

        -   respiratory distress syndrome, or

        -   autopsy findings consistent with pneumonia or respiratory
            distress syndrome without an identifiable cause.

**Epidemiologic Criteria**

-   Travel (including transit in an airport) within 10 days of onset of
    symptoms to an area with current or previously documented or
    suspected community transmission of SARS (see Table), or

-   Close contact§ within 10 days of onset of symptoms with a person
    known or suspected to have SARS

  ----------------- ------------------- ----------------------------------
  **Travel criteria                     
  for suspect or                        
  probable U.S.                         
  cases of SARS**                       

  Area              First date of       Last date of illness onset for
                    illness onset for   inclusion as reported case†
                    inclusion as        
                    reported case‡      

  China (mainland)  November 1, 2002    Ongoing

  Hong Kong         February 1, 2003    Ongoing

  Hanoi, Vietnam    February 1, 2003    May 25, 2003

  Singapore         February 1, 2003    Ongoing

  Toronto, Canada   April 23, 2003      Ongoing

  Taiwan            May 1, 2003         Ongoing
  ----------------- ------------------- ----------------------------------

**Laboratory Criteria¶**

-   Confirmed

    -   Detection of antibody to SARS-CoV in specimens obtained during
        acute illness or \>21 days after illness onset, or

    -   Detection of SARS-CoV RNA by RT-PCR confirmed by a second PCR
        assay, by using a second aliquot of the specimen and a different
        set of PCR primers, or

    -   Isolation of SARS-CoV.

-   Negative

    -   Absence of antibody to SARS-CoV in convalescent serum obtained
        \>21 days after symptom onset.

-   Undetermined

    -   Laboratory testing either not performed or incomplete.

**Case Classification\*\***

-   Probable case: meets the clinical criteria for severe respiratory
    illness of unknown etiology and epidemiologic criteria for exposure;
    laboratory criteria confirmed, negative, or undetermined.

-   Suspect case: meets the clinical criteria for moderate respiratory
    illness of unknown etiology, and epidemiologic criteria for
    exposure; laboratory criteria confirmed, negative, or undetermined.

**Exclusion Criteria**\
A case may be excluded as a suspect or probable SARS case if:

-   An alternative diagnosis can fully explain the illness\*\*\*

-   The case was reported on the basis of contact with an index case
    that was subsequently excluded as a case of SARS (e.g., another
    etiology fully explains the illness) provided other possible
    epidemiologic exposure criteria are not present

> **Also see:**

-   [MMWR: Updated Interim Surveillance Case Definition for Severe Acute
    Respiratory Syndrome (SARS)--- April 29,
    2003](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5217a5.htm)

\_\_\
\* A measured documented temperature of \>100.4º F (\>38º C) is
preferred. However, clinical judgment should be used when evaluating
patients for whom a measured temperature of \>100.4º F (\>38º C) has not
been documented. Factors that might be considered include patient
self-report of fever, use of antipyretics, presence of
immunocompromising conditions or therapies, lack of access to health
care, or inability to obtain a measured temperature. Reporting
authorities should consider these factors when classifying patients who
do not strictly meet the clinical criteria for this case definition.

§ Close contact is defined as having cared for or lived with a person
known to have SARS or having a high likelihood of direct contact with
respiratory secretions and/or body fluids of a patient known to have
SARS. Examples of close contact include kissing or embracing, sharing
eating or drinking utensils, close conversation (\<3 feet), physical
examination, and any other direct physical contact between persons.
Close contact does not include activities such as walking by a person or
sitting across a waiting room or office for a brief period of time.

‡ The WHO has specified that the surveillance period for China should
begin on November 1; the first recognized cases in Hong Kong, Singapore
and Hanoi (Vietnam) had onset in February 2003. The dates for Toronto
and Taiwan are linked to CDC's issuance of travel recommendations.

† The last date for illness onset is 10 days (i.e., one incubation
period) after removal of a CDC travel alert. The case patient's travel
should have occurred on or before the last date the travel alert was in
place.

¶Assays for the laboratory diagnosis of SARS-CoV infection include
enzyme-linked immunosorbent assay, indirect fluorescent-antibody assay,
and reverse transcription polymerase chain reaction (RT-PCR) assays of
appropriately collected clinical specimens (Source: CDC. Guidelines for
collection of specimens from potential cases of SARS. Available at
<http://www.cdc.gov/ncidod/sars/specimen_collection_sars2.htm>). Absence
of SARS-CoV antibody from serum obtained [\<]{.underline}21 days after
illness onset, a negative PCR test, or a negative viral culture does not
exclude coronavirus infection and is not considered a definitive
laboratory result. In these instances, a convalescent serum specimen
obtained \>21 days after illness is needed to determine infection with
SARS-CoV. All SARS diagnostic assays are under evaluation.

\*\* Asymptomatic SARS-CoV infection or clinical manifestations other
than respiratory illness might be identified as more is learned about
SARS-CoV infection.

\*\*\* Factors that may be considered in assigning alternate diagnoses
include the strength of the epidemiologic exposure criteria for SARS,
the specificity of the diagnostic test, and the compatibility of the
clinical presentation and course of illness for the alternative
diagnosis.

**CDC - Interim Guidelines about Severe Acute Respiratory Syndrome
(SARS) for Persons in the General Workplace Environment**\
May 8, 2003, 5:00 PM ET -
<http://www.cdc.gov/ncidod/sars/workplaceguidelines.htm>

[Download PDF version formatted for
print](http://www.cdc.gov/ncidod/sars/pdf/workplace.pdf)
![](media/image6.png){width="0.1673611111111111in"
height="0.1673611111111111in"}(132 KB/1 page)

The Centers for Disease Control and Prevention (CDC) is investigating
the spread of a respiratory illness called severe acute respiratory
syndrome (SARS). CDC has issued various levels of advice for people
traveling to [areas with
SARS](http://www.cdc.gov/ncidod/sars/travel.htm). For some areas, CDC
has issued travel advisories, recommending against nonessential travel.
You can learn more about SARS from the [World Health
Organization](http://www.who.int/csr/sars/en/). These websites will be
updated as soon as new information is learned.

SARS is an infectious illness that appears to spread primarily by close
person-to-person contact, such as in situations in which persons have
cared for, lived with, or had direct contact with respiratory secretions
and/or body fluids of a person known to be a suspect SARS case.
Potential ways in which infections can be transmitted by close contact
include touching the skin of other persons or objects that become
contaminated with infectious droplets and then touching your eyes, nose
or mouth.

Workers, who in the last 10 days have traveled to a known SARS area, or
have had close contact with a co-worker or family member with suspected
or probable SARS could be at increased risk of developing SARS and
should be vigilant for the development of fever (greater than 100.4° F)
or respiratory symptoms (e.g., cough or difficulty breathing). If these
symptoms develop you should not go to work, school, or other public
areas but should seek evaluation by a health-care provider and practice
infection control precautions recommended for the home or residential
setting; **be sure to contact your health-care provider beforehand to
let them know you may have been exposed to SARS so arrangements can be
made, as necessary, to prevent transmission to others in the healthcare
setting.** For more information about the signs and symptoms of SARS,
please visit CDC's website. More detailed guidance on management of
symptomatic persons who may have been exposed to SARS, such as how long
you should avoid public areas is available at the exposure management
page.

As with other infectious illnesses, one of the most important and
appropriate preventive practices is careful and frequent hand hygiene.
Cleaning your hands often using either soap and water or waterless
alcohol-based hand sanitizers removes potentially infectious materials
from your skin and helps prevent disease transmission.

The routine use of personal protective equipment (PPE) such as
respirators, gloves, or, using surgical masks for protection against
SARS exposure is currently not recommended in the general workplace
(outside the health-care setting).

## WHO - First data on stability and resistance of SARS coronavirus compiled by members of WHO laboratory network 

## 4 May 2003 - [**http://www.who.int/csr/sars/survival_2003_05_04/en/index.html**](http://www.who.int/csr/sars/survival_2003_05_04/en/index.html)

This information has been provided by Members of the [WHO multi-center
collaborative network on SARS
diagnosis](http://www.who.int/csr/sars/project/en/). The major
conclusions from these studies are:

Virus survival in stool and urine

-   **Virus is stable in faeces (and urine) at room temperature for at
    least 1-2 days.**

-   **Virus is more stable (up to 4 days) in stool from diarrhea
    patients (which has higher ph) than in normal stool where it could
    only be found for up to 6h.**

**Disinfectants and fixatives (for use in laboratories)**

-   Virus loses infectivity after exposure to different commonly used
    disinfectants and fixatives.

**Virus survival in cell-culture supernatant**

-   Only minimal reduction in virus concentration after 21 days at 4°C
    and -80°C.

-   Reduction in virus concentration by one log only at stable room
    temperature for 2 days. This would indicate that the virus is more
    stable than the known human coronaviruses under these conditions.

-   Heat at 56°C kills the SARS coronavirus at around 10000 units per 15
    min (quick reduction).

<http://www.who.int/csr/sars/map2003_06_11.jpg>

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