Severe Acute Respiratory Syndrome: Established Infectious Disease Control Measures Helped Contain Spread, But a Large-Scale Resurgence May Pose Challenges
Published: 2003-07-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: SARS is a highly contagious respiratory disease that infected more than 8,000 individuals in 29 countries principally throughout Asia, Europe, and North America and led to more than 800 deaths as of July 11, 2003. Due to the speed and volume of international travel and trade, emerging infectious diseases such as SARS are difficult to contain within geographic borders, placing numerous countries and regions at risk with a single outbreak. While SARS did not infect large numbers of individuals in the United States, the possibility that it may reemerge raises concerns about the ability of public health officials and health care workers to prevent the spread of the disease in the United States. GAO was asked to assist the Subcommittee in identifying ways in which the United States can prepare for the possibility of another SARS outbreak. Specifically, GAO was asked to determine 1) infectious disease control measures practiced within health care and community settings that helped contain the spread of SARS and 2) the initiatives and challenges in preparing for a possible SARS resurgence.
section_title: What GAO Found
paragraphs: Infectious disease experts emphasized that no new infectious disease control measures were introduced to contain SARS in the United States. Instead, strict compliance with and additional vigilance to enforce the use of current measures was sufficient. These measures--case identification and contact tracing, transmission control, and exposure management--are well established infectious disease control measures that proved effective in both health care and community settings. The combinations of measures that were used depended on either the prevalence of the disease in the community or the number of SARS patients served in a health care facility. For SARS, case identification within health care settings included screening individuals for fever, cough, and recent travel to a country with active cases of SARS. Contact tracing, the identification and tracking of individuals who had close contact with someone who was infected or suspected of being infected, was important for the identification and tracking of individuals at risk for SARS. Transmission control measures for SARS included contact precautions, especially hand washing after contact with someone who was ill, and protection against respiratory spread, including spread by large droplets and by smaller airborne particles. The use of isolation rooms with controlled airflow and the use of respiratory masks by health care workers were key elements of this approach. Exposure management practices--isolation and quarantine--occurred in both health care and home settings. Effective communication among health care professionals and the general public reinforced the need to adhere to infectious disease control measures. While no one knows whether there will be a resurgence of SARS, federal, state, and local health care officials agree that it is necessary to prepare for the possibility. As part of these preparations, CDC, along with national associations representing state and local health officials, and others, is involved in developing both SARS-specific guidelines for using infectious disease control measures and contingency response plans. In addition, these associations have collaborated with CDC to develop a checklist of preparedness activities for state and local health officials. Such preparation efforts also improve the health care system's capacity to respond to other infectious disease outbreaks, including those precipitated by bioterrorism. However, implementing these plans during a large-scale outbreak may prove difficult due to limitations in both hospital and workforce capacity that could result in overcrowding, as well as potential shortages in health care workers and medical equipment--particularly respirators.

section_title: Letter
paragraphs: I am pleased to be here today as you consider effective infectious disease  control measures to help contain the spread of Severe Acute Respiratory  Syndrome (SARS) should future outbreaks occur. SARS is a highly  contagious respiratory disease that infected more than 8,000 individuals in  29 countries principally throughout Asia, Europe, and North America and  led to more than 800 deaths as of July 11, 2003. Due to the speed and  volume of international travel and trade, emerging infectious diseases such  as SARS are difficult to contain within geographic borders, placing  numerous countries and regions at risk with a single outbreak. SARS  quickly became a worldwide health problem, prompting the World Health  Organization (WHO) to issue a global alert for the first time in more than a  decade—an alert that was cancelled on July 5, 2003. Although the  outbreak is currently believed to be contained, the fact that SARS is a type  of coronavirus—the source of some common colds—leads many to  suggest that SARS could be seasonal and as such could recur in the fall  and winter months.
Although all the modes of SARS transmission may not have been  identified, the disease is most likely spread through person-to-person  contact. Experts agree that infected individuals are contagious when  symptomatic—a time during which they are more likely to seek medical  attention and come into contact with health care workers. One unique  characteristic of the SARS outbreak was the high rate of infection among  health care workers, who—before the institution of specific protective  measures—may have become infected while treating patients with SARS.  The SARS outbreak in Asia demonstrated that the disease can also spread  rapidly in the community, outside of hospital settings.
While SARS did not infect large numbers of individuals in the United  States, the possibility that it may reemerge raises concerns about the  ability of public health officials and health care workers to prevent the  spread of the disease in the United States. To assist the Subcommittee in  identifying ways in which the United States can prepare for the possibility  of another SARS outbreak, my remarks today will focus on 1) infectious  disease control measures practiced within health care and community  settings that helped contain the spread of SARS and 2) the initiatives and  challenges in preparing for a possible SARS resurgence.
My testimony today is based on the review of documentation about  infection control practices and guidelines, as well as descriptions about  the origin of SARS and its spread. In addition, we spoke with leading  national and international disease experts—most of whom were involved  in either the investigation of SARS or in the treatment of patients with  SARS. Specifically, we spoke with experts in infectious diseases,  epidemiology, clinical medicine, and occupational safety from the Centers  for Disease Control and Prevention (CDC) and WHO. We also spoke with  public health officials of Health Canada and Toronto Public Health  because Canada had the highest prevalence of SARS cases in North  America. We interviewed state and local public health officials in  California and New York—both of which had the greatest number of SARS  cases reported in the United States. These officials represented the  California Department of Health Services, the New York State Department  of Health, and the New York City Department of Health and Mental  Hygiene. We also spoke with hospital infectious disease experts in each of  these states. In addition, we spoke with national infectious disease  experts, hospital epidemiologists, and representatives from the National  Association of County and City Health Officials (NACCHO) and the  Association of State and Territorial Health Officials (ASTHO). We also  used our previous work on the capacity of the public health system to  respond to both bioterrorism and emerging infectious diseases. We  conducted our work in July 2003 in accordance with generally accepted  government auditing standards.
In summary, infectious disease experts emphasized that no new infectious  disease control measures were introduced to contain SARS in the United  States. Instead, strict compliance with and additional vigilance to enforce  the use of current measures was sufficient. These measures—case  identification and contact tracing, transmission control, and exposure  management—are well-established infectious disease control measures  that proved effective in both health care and community settings. The  combinations of measures that were used depended on either the  prevalence of the disease in the community or the number of SARS  patients served in a health care facility. For SARS, case identification  within health care settings included screening individuals for fever, cough,  and recent travel to a country with active cases of SARS. Contact tracing,  the identification and tracking of individuals who had close contact with  someone who was infected or suspected of being infected, was important  for the identification and tracking of individuals at risk for SARS.
Transmission control measures for SARS included contact precautions,  especially hand washing after contact with someone who was ill, and  protection against respiratory spread, including spread by large droplets  and by smaller airborne particles. The use of isolation rooms with  controlled airflow and the use of respiratory masks by health care workers  were key elements of this approach. Exposure management practices— isolation and quarantine—occurred in both health care and home settings.  Effective communication among health care professionals and the general  public reinforced the need to adhere to infectious disease control  measures.
While no one knows whether there will be a resurgence of SARS, federal,  state, and local health care officials we interviewed agree that it is  necessary to prepare for the possibility. As part of these preparations,  CDC, along with national associations that represent state and local health  officials, and others, is involved in developing both SARS-specific  guidelines for using infectious disease control measures and contingency  response plans. In addition, these associations have collaborated with  CDC to develop a checklist of preparedness activities for state and local  health officials. Such preparation efforts also improve the health care  system’s capacity to respond to other infectious disease outbreaks,  including those precipitated by bioterrorism. However, implementing  these plans may prove difficult due to limitations in both hospital and  workforce capacity. A large-scale SARS outbreak could create  overcrowding, as well as shortages in health care workers and in medical  equipment—particularly respirators.
subsections: section_title: Background
paragraphs: SARS is an emerging respiratory disease that has been reported principally  in Asia, Europe, and North America. SARS is believed to have originated in  Guangdong Province, China in mid-November 2002. However, early cases  of the disease went unreported, which then delayed identification and  treatment of the disease allowing it to spread. On February 11, 2003, WHO  received its first official report of an atypical pneumonia outbreak in  China. This report stated that 305 individuals were affected by atypical  pneumonia and that 5 deaths had been attributed to the disease. SARS was  transmitted out of the Guangdong Province on February 21, 2003, by a  physician who became infected after treating patients in the province.  Subsequently, the physician traveled to a hotel in Hong Kong and began  suffering from flu-like symptoms. Days later, other guests and visitors at  the hotel contracted SARS. As infected hotel patrons traveled to other  countries, such as Vietnam and Singapore, and sought medical attention  for their symptoms, they spread the disease throughout each country’s  hospitals as well as in some communities. Simultaneously, the disease  began spreading around the world along international air travel routes as  guests from the hotel flew homeward to Toronto and elsewhere.
subsections: section_title: Description of Severe Acute Respiratory Syndrome
paragraphs: Scientific evidence indicates that SARS is caused by a previously  unrecognized coronavirus. Transmission of SARS appears to result  primarily from close person-to-person contact and contact with large  respiratory droplets emitted by an infected person who coughs or sneezes.  After contact, the incubation period for SARS—the time it takes for  symptoms to appear after an individual is infected—is generally within a  10-day period. Clinical evidence to date also suggests that people are most  likely to be contagious at the height of their symptoms. However, it is not  known how long after symptoms begin that patients with SARS are  capable of transmitting the virus to others. There is no evidence that SARS  can be transmitted from asymptomatic individuals.
Currently, there is no definitive test to identify SARS during the early  phase of the illness, which complicates diagnosing infected individuals. As  a result, the early diagnosis of SARS relies more on interpreting  individuals’ symptoms and identification of travel to locations with SARS  transmission. SARS symptoms include fever, chills, headaches, body  aches, and respiratory symptoms such as shortness of breath and dry  cough—making SARS difficult to distinguish from other respiratory  illnesses, such as the flu and pneumonia. The initial symptoms can be quite  mild, and gradually increase in severity, often peaking in the second week  of illness. In some individuals, the disease might progress to the point  where insufficient oxygen is getting to the blood.
CDC has established for health care providers criteria used for the  identification of individuals with SARS, called case definitions. In the  absence of a definitive diagnostic test for the disease in its early phase,  reported cases of SARS are classified into two categories based on clinical  and epidemiologic criteria—“suspect” and “probable.” These case  definitions continue to be refined as more is learned about this disease. A  “suspect” case of SARS includes the following criteria:  respiratory illness, and  recent travel to an area with current or previously documented suspected  transmission of SARS, and/or    close contact within 10 days of the onset of symptoms with a person  known or suspected to have SARS.
A “probable” case of SARS includes the following criteria:    all the criteria for “suspect” cases and    evidence in the form of chest x-ray findings of pneumonia, acute  respiratory distress syndrome (ARDS), or an unexplained respiratory  illness resulting in death with autopsy findings of ARDS.
The final determination of whether cases meeting the definitions for  “suspect” and “probable” SARS are due to infection with the SARS virus is  based on results of testing a blood specimen obtained 28 days after the  onset of illness.
Furthermore, there is no specific treatment for SARS. In the absence of a  rapid diagnostic test, it can be very difficult to distinguish clinically  between individuals with SARS and individuals with atypical pneumonia.  Therefore, CDC currently recommends that individuals suspected of  having SARS be managed using the same diagnostic and therapeutic  strategies that would be used for any patient with serious atypical  pneumonia. In mild cases of SARS, management at home may be  appropriate, while more severe cases may require treatment, such as  intravenous medication and oxygen supplementation, that necessitates  hospitalization. In 10 to 20 percent of SARS cases, patients require  mechanical ventilation. As of July 11, 2003, the mortality rate for SARS  was approximately 10 percent, but the mortality rates in individuals over  60 years of age approached 50 percent.
As of July 11, 2003, WHO reported that there were an estimated 8,427  “probable” cases from 29 countries, with 813 deaths from SARS. China,  Hong Kong, Singapore, Taiwan, and Canada reported the highest number  of cases. As of July 15, 2003, the United States identified 211 SARS cases in  39 states (including Puerto Rico), with no related deaths. Of these cases,  175 are classified as “suspect” cases, while 36 are classified as “probable.”  In the United States, 34 of the 36 “probable” cases contracted SARS  through international travel. However, in the other affected countries,  SARS spread extensively among health care workers. For example, of the  138 diagnosed cases in Hong Kong as of March 25, 2003, that were not due  to travel, 85 (62 percent) occurred among health care workers; among the  144 cases in Canada as of April 10, 2003, 73 (51 percent) were health care  workers.
section_title: General Infectious Disease Control Measures
paragraphs: In the United States, the Healthcare Infection Control Practices Advisory  Committee (HICPAC), a federal advisory committee made up of 14  infection control experts, develops recommendations and guidelines  regarding general infectious disease control measures for CDC. Important  components of these infectious disease control measures are the  following: case identification and contact tracing, transmission control,  and exposure management.
Case Identification and Contact Tracing. Case identification and  contact tracing are considered by health care providers to be important  first steps in the containment of infectious diseases in both the community  and health care settings. Case identification is the process of determining  whether or not a person meets the specific definitions for a given disease.  Generally, health care providers interview patients in order to obtain the  history, signs, and symptoms of the patient’s complaint and perform a  physical examination. Tests, such as blood tests or x-rays, can be  performed to provide additional information to help determine the  diagnosis. Public awareness of the symptoms of a disease can help case  identification to the extent that individuals who believe they exhibit the  symptoms seek medical attention. Contact tracing involves the  identification and tracking of individuals who may have been exposed to a  person with a specific disease.
Transmission Control. Transmission control measures decrease the risk  for transmission of microorganisms through proper hand hygiene and the  use of personal protective equipment, such as masks, gowns, and gloves.  These measures also include the decontamination of objects and rooms.  The types of transmission control measures used are based on how an  illness is transmitted. For example, some categories of transmission are as  follows:    Direct contact: person-to-person contact (e.g., two people shaking hands)  and physical transfer of the microorganism between an infected person  and an uninfected person.  Indirect contact: contact with a contaminated object, such as secretions  from an infected person on a doorknob or telephone receiver.
Droplet: eye, nose, or mouth of an uninfected person coming into contact  with droplets (larger than 5 micrometers) containing the microorganism  from an infected person, for example an infected person sneezing without  covering his/her mouth with a tissue.
Airborne: contact with small droplets (5 micrometers or smaller) or dust  particles containing the microorganism, which are suspended in the air.
Exposure Management. Exposure management is the separation of  infected individuals from noninfected individuals through isolation or  quarantine. Isolation refers to the separation of individuals who have a  specific infectious illness from healthy individuals and the restriction of  their movement to contain the spread of that illness. Quarantine refers to  the separation and restriction of movement of individuals who are not yet  ill, but who have been exposed to an infectious agent and are potentially  infectious.
The success of these infectious disease control measures—case  identification and contact tracing, transmission control, and exposure  management—depends, in part, on the frequent and timely exchange of  information. Public health officials and health care providers need to be  informed about any modifications of existing infectious disease control  measures, the geographic progression of an outbreak, and reports of  disease occurrence. Likewise, elevating public knowledge about an  infectious disease and its symptoms will enable infected individuals to  seek medical attention as soon as possible to contain the spread.
section_title: Experts Recommend Case Identification and Contact Tracing, Transmission Control, and Exposure Management Measures To Prevent the Spread of SARS
paragraphs: Infectious disease experts emphasized that existing infectious disease  control measures played a pivotal role in containing the spread of SARS in  both health care and community settings. The combinations of measures  that were used depended on either the prevalence of the disease in the  community or the number of SARS patients served in a health care facility.  No new measures were introduced to contain the SARS outbreak in the  United States; instead, experts said strict compliance with and additional  vigilance to enforce the use of current measures was sufficient. The  successful implementation of all of the infectious disease control  measures depended, in part, on effective communication among health  care professionals and the general public.
subsections: section_title: Timely Case Identification and Contact Tracing of SARS Cases Was Critical But Difficult
paragraphs: To prevent the spread of SARS, public health authorities worked to  identify every individual who might have been infected with the disease.  Rapid identification of these individuals was critical, but the lack of an  effective and timely diagnostic test that could be used during the early  stages of the disease to identify those who actually had SARS was an  obstacle in halting its spread. Experts acknowledged that identification of  individuals who might have been infected with the SARS virus was likely  to include many people who did not have SARS because the case  definition of an individual with SARS is not highly specific and the disease  resembles other respiratory illnesses, such as pneumonia and the flu. The  long incubation period for SARS provided health care workers the  opportunity to identify cases and close contacts of infected individuals  before those who actually had the SARS virus could spread the disease to  others.
An important part of case identification is screening individuals for  symptoms of a disease. CDC recommended that when individuals called  for appointments and as soon as possible after the individual arrived in a  health care setting, all individuals should be screened with targeted  questions concerning SARS-related symptoms, close contact with a SARS  suspect case patient, and recent travel. For SARS, public health and  hospital officials in California and New York said hospital emergency  room or other waiting room staff routinely used questionnaires to screen  incoming patients for fever, cough, and travel to a country with active  cases of SARS. They said that hospitals’ signs in various locations  generally used by incoming patients and visitors also included these  criteria and asked individuals to identify themselves to hospital staff if  they met them. According to these officials, an individual identified as a  potential SARS case generally was given a surgical mask and moved into a  separate area for further medical evaluation. CDC officials said that these  measures were also important for physicians in private practice. The New  York City and California health departments used e-mail health alert  notices to inform private physicians, such as family practitioners and  pediatricians, about these case identification procedures. These notices  directed physicians to information posted on the health departments’ Web  sites. In addition, officials from these health departments provided  information about SARS case identification, among other topics, during  local meetings for members of the medical community, including  physicians in private practice.
Toronto, which experienced a much greater prevalence of SARS than the  United States, used somewhat different case identification practices. At  the height of the outbreak in Toronto, everyone entering a hospital was  required to answer screening questions and to have their temperature  checked before they were allowed to enter. Toronto public health  department officials said this heightened screening was useful for case  identification and had an added benefit of educating staff and visitors  about SARS symptoms. As a further measure, Toronto health officials  established SARS assessment clinics, also known as fever clinics; persons  suspecting they might have SARS were asked to go to the clinics rather  than directly to hospital emergency rooms to avoid infecting other  individuals. However, officials acknowledged several limitations to using  these assessment clinics. Because there was no follow-up to an initial  assessment, some SARS cases that were in the early stages were not  identified, but later these individuals went to hospital emergency rooms.  Other difficulties included finding physicians to staff the clinics and  implementing hospital-level infectious disease control measures at these  separate clinics. For example, some clinics were set up in non-hospital  locations—one assessment clinic was set up in a tent near a hospital  emergency room entrance, while another was situated in a hospital  ambulance bay where emergency personnel transfer patients into the  hospital.
Contact tracing—the identification and tracking of individuals who had  close contact with a “suspect” or “probable” case—is an important  component of case identification. Contact tracing to identify individuals at  significant risk for SARS required significant local health department  resources. In New York City, four teams from the communicable disease  bureau, comprised of either a physician or nurse and several field workers,  interviewed each suspect or probable case in order to identify contacts.  They then called each contact to advise them of their exposure and  provided information on monitoring for symptoms of SARS and receiving  treatment if necessary. The calls were also to ensure that the contacts  were following infection control measures in the home. Each contact  received routine calls during a 10-day period—an average of four calls  each from a team member. A New York City health department official  characterized the process of contact tracing as labor and time intensive.  Standardized forms and electronic contact and case databases helped the  teams manage contact tracing. Additionally, routine weekly meetings with  other health department divisions ensured that if assistance was needed  from these departments, they would be up-to-date. Furthermore, New  York City developed procedure manuals that would allow staff from other  departments to be trained quickly if needed to assist members of the  communicable disease bureau. The health department official emphasized  that the electronic database created to log information about SARS  contacts was an important tool to facilitate contact tracing. Toronto  officials agreed that daily contact tracing required a large amount of  resources. Adding to Toronto’s difficulties, its health department did not  have an electronic case or contact database, but had to rely on separate  paper files for each individual.
section_title: Multiple Transmission Control Measures Used to Contain Spread
paragraphs: Experts recommended a combination of transmission control measures  because not all modes of SARS transmission are known. The primary  mode of transmission is direct person-to-person contact, although contact  with body fluids and contaminated objects, and possibly airborne spread,  may play a role. Therefore, multiple infection control practices that are  used for each type of transmission are included in SARS infection control  guidelines. Some combination of practices was recommended for both  health care settings and in the community, with more intensive infection  control procedures recommended for health care settings. According to  several experts, the simple “things your mother taught you,” such as  washing your hands and covering your mouth and nose with a tissue when  sneezing or coughing were effective in reducing the spread of SARS.
CDC prepared SARS guidelines for transmission control measures for both  inpatient (such as hospitals) and outpatient (such as physician offices)  health care settings. These recommendations combined what the CDC  calls “standard” hospital transmission control measures with transmission  control measures specific to contact and airborne transmission. For the  inpatient setting, the guidelines included:    Routine standard precautions, including hand washing. In addition to  standard precautions, CDC recommended eye protection—such as goggles  or a face shield.
Contact precautions, such as the use of a gown and gloves for encounters  with the patient or his/her environment.
Airborne precautions, such as an isolation room with negative pressure  relative to the surrounding area, and the use of an N-95 filtering  disposable respirator for persons entering the room. The CDC guidelines  suggested that if an isolation room was not available, patients should be  placed in a private room, and all persons entering the room should wear N- 95 respirators (or respirators offering comparable protection) to protect  the wearer from particles expelled by a sick person, such as in coughing or  sneezing. CDC recommended that, where possible, a test to ensure that the  N-95 respirators fit properly should be conducted. If N-95 respirators were  not available for health care personnel, then surgical masks should be  worn. Generally, the material of N-95 respirators is designed to filter  smaller particles than a surgical mask, and they also are designed to seal  more tightly to the face.
The health department and hospital officials we spoke with said they  generally adopted these CDC guidelines for transmission control in  inpatient settings. Officials said one of the most effective practices to  contain SARS was frequent hand washing with soap and water. CDC  guidelines also allow the use of waterless alcohol-based hand rubs after  coming in contact with “suspect” or “probable” SARS patients or their  environments. Additionally, a hospital and a health department official  said careful cleaning of SARS patient rooms was an important hygiene  measure.
Inpatient facilities in the United States generally saw few SARS patients. In  New York and California, the hospital officials stated that because of the  small number of cases that were seen in each hospital, usually only one or  two at a time, the hospitals were able to manage SARS patients in available  isolation rooms. Because of the greater prevalence of SARS in Toronto, all  22 acute care hospitals were directed to have a SARS unit with negative  pressure to the rest of the hospital, individual rooms, and specific staff  who only cared for SARS patients. Toronto health department officials  later were able to designate four hospitals as SARS hospitals and direct all  SARS patients to these four facilities.
The use of face masks or N-95 respirators was highly recommended by  experts as an effective means of transmission control for SARS in  inpatient settings. In one study of health care workers who had extensive  contact with SARS patients in five Hong Kong hospitals, researchers found  that no health care worker who consistently used either type of face  covering became infected. Experts also noted that the use of N-95  respirators and isolation rooms was especially important for high-risk  medical procedures, such as intubation, where a patient’s secretions are  likely to be transformed into a fine spray and spread for a longer distance  than large droplets. Officials cautioned, however, that there can be  difficulties in the use of N-95 respirators. One public health official said  that compliance may be limited in hospitals in several ways—either staff  has never been properly fitted for the respirators, or some staff who were  fitted many years ago should have a more recent fitting. In Canada,  Ontario’s health ministry directed health care workers in the province  (which includes Toronto) to employ an additional level of protective  equipment when conducting high-risk medical procedures that was not  recommended in the United States. For example, health care workers used  a protective system that included a hood, a full-face respirator, and a  complete body covering such as long-sleeved floor-length gowns and  gloves.
The CDC guidelines for outpatient settings included the same standard  and contact precautions outlined for inpatient settings. Reflecting the  different types of facilities likely available in a physician office compared  to a hospital, for example, outpatient guidelines did not advocate the use  of specialized isolation rooms. Instead, for outpatient settings, the  guidelines advised health care personnel to separate the potential SARS  patient from others in a reception area as soon as possible, preferably in a  private room with negative pressure relative to the surrounding area. At  the same time, the guidelines said that a surgical mask should be placed  over the patient’s nose and mouth—if this was not feasible, the patient  should be asked to cover his or her mouth with a disposable tissue when  coughing, talking, or sneezing.
Transmission control guidelines for community settings incorporated  many of the same types of measures for containing the spread of SARS as  recommended for health care settings. CDC published SARS transmission  control guidelines for two community settings—the workplace and  households. The workplace guidelines recommended frequent hand  washing with soap and water or waterless alcohol-based hand rubs. Along  with handwashing, guidelines for household transmission control included  the following:  Infection control precautions should be continued for SARS patients for 10  days after respiratory symptoms and fever are gone. SARS patients should  limit interactions outside the home and should not go to work, school, out- of-home day care, or other public areas during the 10-day period.
During this 10-day period, each patient with SARS should cover his or her  mouth and nose with a tissue before sneezing or coughing. If possible, a  person recovering from SARS should wear a surgical mask during close  contact with uninfected persons. If the patient is unable to wear a surgical  mask, other people in the home should wear one when in close contact  with the patient.
Disposable gloves should be considered for any contact with body fluids  from a SARS patient. Immediately after activities involving contact with  body fluids, gloves should be removed and discarded, and hands should be  washed. Gloves should not be washed or reused, and were not intended to  replace proper hand hygiene.
SARS patients should avoid sharing eating utensils, towels, and bedding  with other members of the household, although these items could be used  by others after routine cleaning, such as washing or laundering with soap  and hot water.
Frequent use should be made of common household cleaners for  disinfecting toilets, sinks, and other surfaces touched by patients with  SARS.
section_title: Exposure Management Used to Prevent SARS Spread
paragraphs: Exposure management methods such as isolation and quarantine are  important infectious disease control measures. These measures were  particularly effective for SARS because of its long incubation period  during which infected individuals could be isolated before they become  contagious. In fact, experts stated that isolation of infected individuals and  quarantine measures used for exposed individuals were critical for the  containment of SARS.
Isolation of SARS infected individuals occurred in both health care and  home settings. In Toronto, patients were typically isolated in the  hospital—even in cases where individuals were not ill enough to need  hospitalization. During the height of Toronto’s outbreak, all 22 acute care  hospitals were directed to have separate SARS units. On the other hand, in  the United States, individuals were hospitalized only if they needed  intensive medical treatment. According to an infectious disease expert  who consulted with the CDC, this practice was prompted by concerns that  grouping SARS cases together, such as in a hospital ward, could increase  the likelihood of spread to both health care workers and other hospital  patients.
For home isolation in New York City, each patient and contact was given  detailed information that included instructions on what to do if ill,  reminders of the importance of calling ahead before going to a physician’s  office or other health care settings, and information on how to travel to a  health care setting without coming in contact with others. These  instructions also included guidelines for transmission control measures to  be used in the home. For all probable cases, the New York City health  department conducted a home assessment to ensure that a SARS patient  could be adequately isolated at home, which included the need for such  things as adequate ventilation and bathrooms that would not be shared by  noninfected individuals.
Quarantine of exposed individuals was based on different parameters,  depending on the number of “suspect” or “probable” SARS cases in the  community. CDC officials said the agency’s guidance reflected the fact  that there was little or no transmission of SARS in the United States, and  therefore quarantine was less warranted because there were so few cases  in a community. CDC’s guidance advised individuals who were exposed  but not symptomatic to monitor themselves for symptoms—such as fever,  a cough, and difficulty breathing, and further advised home isolation and  medical evaluation if symptoms began. CDC officials also advised transfer  to a hospital only if the illness became severe.
In contrast, Toronto, which experienced a high level of person-to-person  transmission, used a more conservative quarantine standard. Individuals  who did not have symptoms but had been in contact with SARS infected  individuals were ordered to stay in their homes and avoid public  gatherings for 10 days. Thousands people were asked to undergo  quarantine in their homes in the Toronto area. During the outbreak,  exposed Toronto health care workers were restricted to “work  quarantine”—they were only allowed to travel to and from work alone in  their vehicles, but they were not allowed to have visitors or visit public  places. Quarantine efforts in Toronto again required a high level of  resources. Daily phone calls required 60 staff per 1,000 people who were  quarantined in the Toronto area; these staff worked 7 days a week to  follow up with twice-daily calls to each individual.
section_title: Success in Implementing Infectious Disease Control Measures Depended on Rapid and Frequent Communication
paragraphs: According to health officials, rapid and frequent communications of  crucial information about SARS—such as the level of outbreak worldwide  and recommended infectious disease control measures—were vital  components of the efforts to contain the spread of SARS. Since March  2003, health organizations have shared extensive SARS-related  information and guidelines with health care workers. For example, WHO  scheduled numerous press briefings that updated the health community  about the status of international SARS containment and prevention efforts.  WHO, with CDC support, sponsored a videoconference broadcast globally  to discuss the latest findings of the outbreak and prevention of  transmission in health care settings (which was also available for  computer download). CDC activated its Emergency Operations Center and  devoted over 800 medical experts and support personnel worldwide to  provide round-the-clock coordination and response to the SARS outbreak.  CDC also had regular conference calls and information-sharing sessions  with various medical professional associations and state and local health  departments and laboratories.
At the state level, the California health department utilized the California  Health Alert Network to send e-mails with SARS information (often based  on CDC information) to all local health departments and many hospitals  and physicians. The New York City health department hosted a  symposium specifically for health care workers, to share the latest  available SARS information. Hospital officials we spoke with also offered  training seminars for their health care personnel on the signs and  symptoms of SARS, recommended screening questions, and appropriate  infectious disease control measures. Furthermore, hospitals kept their  patients informed about SARS via posters and flyers throughout their  facilities, especially in emergency room waiting areas.
Health organizations maintained open and frequent communications in the  community setting to facilitate the containment of SARS. For example, in a  2-week period early in the SARS outbreak, CDC conducted nine telephone  press conferences with the media to keep the public informed about the  latest SARS information, including numbers of “suspect” and “probable”  SARS cases, laboratory and surveillance findings, travel advisories, and  CDC’s efforts nationally and worldwide. CDC also distributed more than  two million health alert notices to travelers entering the United States  from China, Hong Kong, Singapore, Taiwan, Vietnam, or Toronto. These  cards, printed in eight languages, asked individuals to monitor their health  for at least 10 days and to contact their health care provider if they  exhibited SARS symptoms. A state and a local health official also stressed  the importance of informing and educating the general public in  workplaces and schools on the signs and symptoms of SARS, an effort  which was intended to foster self-identification, minimize panic, and  assuage fears of being infected.
Public health officials also concurred that collaboration between federal,  state, and local health agencies as well as the medical community was  crucial in containing the spread of SARS. Through the collaboration of all  the appropriate players, coordination of prevention activities could be  maintained, roles could be identified and assigned, available resources  could be shared, and subsequent evaluations could be conducted. For  instance, the Toronto health department maintained active  communications with its local, provincial, and national governments in  regard to isolation and quarantine practices, travel jurisdictions, and other  SARS-related matters. The health department published directives for all  Toronto area health care providers, outlining their SARS-related roles and  responsibilities. The health department also maintained ongoing contact  with identified liaisons at Toronto hospitals where SARS patients were  hospitalized. Furthermore, the city of Toronto activated its local  emergency operations center, which brought together emergency medical  services, police, and community neighborhood planners to work together  to contain SARS. Throughout Toronto’s efforts, numerous briefings and  teleconferences were organized to keep all players abreast about the latest  SARS information in the community.
section_title: Federal, State, and Local Health Officials Are Preparing for a Possible SARS Resurgence, But Implementing Plans May Pose Challenges if the Resurgence Is Large-Scale
paragraphs: While no one knows whether there will be a resurgence of SARS, federal,  state, and local health care officials we interviewed agree that it is  necessary to prepare for the possibility. As part of these preparations,  CDC, along with national associations that represent state and local health  officials, and others, is involved in developing SARS-specific guidelines for  using infectious disease control measures and contingency response plans.  In addition, these associations have collaborated with CDC to develop a  checklist of preparedness activities for state and local health officials.  Such preparation efforts also improve the health care system’s capacity to  respond to other infectious disease outbreaks, including those precipitated  by bioterrorism. However, implementing these plans may prove difficult  due to limitations in both hospital and workforce capacity. A large-scale  SARS outbreak could create overcrowding, as well as shortages in medical  equipment (including N-95 respirators) and in health care personnel, who  are at higher risk for infection due to their more frequent exposure to a  contaminated environment.
subsections: section_title: Federal, State, and Local Health Officials Are Preparing for the Possibility of Future Outbreaks
paragraphs: At the federal level, CDC has begun contingency planning for a SARS  outbreak, having convened a task force of infection control experts who  are responsible for developing SARS-specific guidelines and  recommendations, which address various infection control measures. The  task force plans to publish its guidelines and recommendations by  September 2003. CDC is collaborating with several professional  associations, such as the Council of State and Territorial Epidemiologists,  ASTHO, and NACCHO, to develop these response plans that vary  according to the prevalence of the disease and the type of setting (i.e.,  health care or community) in which control measures need to be  implemented.
At the state and local levels, health departments are also in the process of  developing contingency response plans for SARS. To facilitate this,  ASTHO and NACCHO, in collaboration with CDC, published a checklist  for state and local health officials to use in the event of a SARS  resurgence. The SARS preparations have been modeled after a checklist  designed for pandemic influenza. The checklist encompasses a broad  spectrum of preparedness activities, such as legal issues related to  isolation and quarantine, strategies for communicating information to  health care providers, and suggestions for ensuring other community  partners such as law enforcement and school officials are prepared (see  app. I for a copy of the checklist).
In specific local preparedness efforts, California and New York, which had  the highest number of SARS cases in the United States, are also preparing  for a large-scale SARS outbreak. For example, California health  department officials said they were developing a plan for surge capacity by  considering staff rotations or details of health department specialists to  maintain a high level of response during a potential SARS outbreak.  Similarly, officials with the New York City health department said they had  created a formal procedure manual, which outlines the roles of reallocated  staff from various teams in the department, to help contain a large-scale  SARS outbreak.
section_title: Limitations in Hospital and Workforce Capacity Make Implementing Infectious Disease Control Measures Difficult in the Event of a Large-Scale SARS Outbreak
paragraphs: While hospital officials we spoke with stated that they are taking steps to  ensure that they have the necessary preparations to address a large-scale  SARS outbreak, hospitals may still be limited in their capacity to respond.  Because of the inability to precisely determine if someone has SARS, many  people may be treated who do not have the virus. In the event of a large- scale outbreak, this imprecision may result in severe overcrowding in  health care settings—especially if a SARS resurgence occurs during a peak  season for another respiratory disease like influenza. This could strain the  available capacity of hospitals. For example, public health officials with  whom we spoke said that in the event of a large-scale SARS outbreak,  entire hospital wards (along with their staff) may need to be used as  separate SARS isolation facilities. Moreover, certain hospitals within a  community might need to be designated as SARS hospitals.
We recently reported that most hospitals lack the capacity to respond to  large-scale infectious disease outbreaks. Most emergency departments  have experienced some degree of crowding and therefore, in some cases,  may not be able to handle a large influx of patients during a potential  outbreak of SARS or another infectious disease. Few hospitals have  adequate staff, medical resources, and equipment, such as N-95  respirators, needed to care for the potentially large numbers of patients  that may seek treatment. We reported that in the seven cities we visited,  hospital, state, and local officials indicated that hospitals needed  additional equipment and capital improvements—including medical  stockpiles, personal protective equipment, quarantine and isolation  facilities, and air handling and filtering equipment—to enhance  preparedness. According to our survey of over 2,000 hospitals, the  availability of medical equipment varied greatly among hospitals, and few  hospitals reported having the equipment and supplies needed to handle a  large-scale infectious disease outbreak. Half the hospitals we surveyed  had, for every 100 staffed beds, fewer than 6 ventilators, 3 or fewer  personal protective equipment suits, and fewer than 4 isolation beds.
Workforce capacity issues may also hinder implementation of infectious  disease control measures. Health officials noted that there is a lack of  qualified and trained personnel, including epidemiologists, who would be  needed in the event of a SARS resurgence. This shortage could grow worse  if, in the event of a severe outbreak, existing health care workers became  infected as a result of their more frequent exposure to a contaminated  environment or became exhausted working longer hours. Workforce  shortages could be further exacerbated because of the need to conduct  contact tracing. According to WHO officials, an individual infected with  SARS came into contact with, on average, 30 to 40 people in Asian  countries—all of whom had to be contacted and informed of their possible  exposure. In contrast, New York City health department officials said that  infected individuals came into contact with 4 people on average.
In addition, the monitoring of individuals placed under isolation and  quarantine may strain resources if widespread isolations and quarantines  are needed. For example, follow-up with isolated or quarantined  individuals requires significant resources. Officials of the New York City  Department of Health and Mental Hygiene said that they made home visits  to SARS cases when officials became concerned that these individuals  were not following infection control measures or were not remaining in  their homes. Similarly, Canadian public health officials said that they, and  in some cases Canadian police, made home visits to check compliance  with quarantine orders. These officials also described the difficulty in  providing necessary resources (food, medicines, masks, and  thermometers) to individuals under isolation or quarantine. In Canada,  police and the Red Cross had to help deliver food to those under isolation  or quarantine.
section_title: Concluding Observations
paragraphs: The global spread of SARS was contained through an unprecedented level  of international scientific collaboration and the use of well-established  infection control measures that have been used effectively in the past to  control diseases. Although questions remain about SARS, especially about  the ways it can be transmitted, many lessons were learned that could be  helpful to the United States in the event of a resurgence. Lessons to carry  forward are the importance of early identification of infected individuals  and their contacts, the effectiveness of safety precautions to control  transmission and ensure the protection of health care workers, and the  need to use, in some cases, isolation and quarantine. Swift and unfettered  communication among heath care workers, public health officials,  government agencies, as well as the public provided the essential  backbone to support ongoing efforts to contain the disease.
Although SARS is currently believed to be contained, now is the time to  prepare for the possibility of a future outbreak. Some preparations are  already underway and encompass, in large part, approaches similar to  those for pandemic influenza and are also part of general bioterrorism  preparedness. Worldwide disease surveillance would facilitate prompt  identification of a resurgence of SARS, allowing rapid implementation of  infectious disease control measures that would reduce both the spread of  SARS and the risk of a large outbreak. Should a large-scale outbreak occur  in the near term, limitations in the capacity of our nation’s health system  to undertake effective and rapid implementation of infectious disease  control measures could prove problematic. A major SARS outbreak would  necessitate rapid escalation of infectious disease control resources  including health care workers, emergency room and hospital capacity, and  the requisite control and support equipment.
Mr. Chairman, this completes my prepared statement. I would be happy to  respond to any questions you or other Members of the Subcommittee may  have at this time.
section_title: Contact and Staff Acknowledgments
paragraphs: For more information regarding this testimony, please contact Marjorie  Kanof at (202) 512-7101. Bonnie Anderson, Karen Doran, John Oh, Danielle  Organek, and Krister Friday also made key contributions to this statement.
section_title: Related GAO Products
paragraphs: SARS Outbreak: Improvements to Public Health Capacity are Needed for  Responding to Bioterrorism and Emerging Infectious Diseases. GAO-03- 769T. Washington, D.C.: May 7, 2003.
Smallpox Vaccination: Implementation of National Program Faces  Challenges. GAO-03-578. Washington, D.C.: April 30, 2003.
Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have  Improved Public Health Response Capacity, but Gaps Remain. GAO-03- 654T. Washington, D.C.: April 9, 2003.
Bioterrorism: Preparedness Varied across State and Local Jurisdictions.  GAO-03-373. Washington, D.C.: April 7, 2003.
Hospital Emergency Departments: Crowded Conditions Vary among  Hospitals and Communities. GAO-03-460. Washington, D.C.: March 14,  2003.
Homeland Security: New Department Could Improve Coordination but  Transferring Control of Certain Public Health Programs Raises  Concerns. GAO-02-954T. Washington, D.C.: July 16, 2002.
Homeland Security: New Department Could Improve Biomedical R&D  Coordination but May Disrupt Dual-Purpose Efforts. GAO-02-924T.  Washington, D.C.: July 9, 2002.
Homeland Security: New Department Could Improve Coordination but  May Complicate Priority Setting. GAO-02-893T. Washington, D.C.: June  28, 2002.
Homeland Security: New Department Could Improve Coordination but  May Complicate Public Health Priority Setting. GAO-02-883T.  Washington, D.C.: June 25, 2002.
Bioterrorism: The Centers for Disease Control and Prevention’s Role in  Public Health Protection. GAO-02-235T. Washington, D.C.: November 15,  2001.
Bioterrorism: Review of Public Health Preparedness Programs. GAO-02- 149T. Washington, D.C.: October 10, 2001.
Bioterrorism: Public Health and Medical Preparedness. GAO-02-141T.  Washington, D.C.: October 9, 2001.
Bioterrorism: Coordination and Preparedness. GAO-02-129T.  Washington, D.C.: October 5, 2001.
Bioterrorism: Federal Research and Preparedness Activities. GAO-01- 915. Washington, D.C.: September 28, 2001.
West Nile Virus Outbreak: Lessons for Public Health Preparedness.  GAO/HEHS-00-180. Washington, D.C.: September 11, 2000.
Combating Terrorism: Need for Comprehensive Threat and Risk  Assessments of Chemical and Biological Attacks. GAO/NSIAD-99-163.  Washington, D.C.: September 14, 1999.
Combating Terrorism: Observations on Biological Terrorism and Public  Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16,  1999.
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