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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

Summary: 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. 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.