Download CMO cascade letter 30th April

1
Wednesday 30th April 2003
To:
Chief Executives of NHS Trusts to forward to:
- Medical Directors of NHS Trusts
- Nursing Directors of NHS Trusts
Chief Executives of Local Health Boards to forward to:
- Chairmen of LHBs
Copies:

Director National Public Health Service

Regional Directors of Public Health

Regional Directors of the National Health Service

Director for Infection and Communicable Disease NPHS

Director CDSC Wales

Consultants in Communicable Disease Control

Directors of Public Health in Local Health Boards

Medical Officers in Ports and Airports

Chief Executives of Local Authorities
Dear Colleague,
SEVERE ACUTE RESPIRATORY SYNDROME (SARS)
1. This letter follows CMO’s earlier communications on 14 March 2003
(reference
CEM/CMO/2003/5)
and
7
April
2003
(reference
CEM/CMO/2003/6) on the newly emergent infectious disease – Severe
Acute Respiratory Syndrome (SARS) – which has been the subject of a
global
alert
by
the
World
Health
Organisation
(WHO).
IMMEDIATE ACTION REQUIRED
2. The purpose of this letter is to remind NHS Trust Chief Executives of the
action that they need to take within their organisations as a precaution in
case of further suspected cases of SARS presenting to the NHS and the
action that must be taken when dealing with such a case.
3. You will have in place protocols for managing infectious patients, including
in Accident and Emergency Departments. In planning the further action
that needs to be taken, NHS Trust Chief Executives should be aware that
the key to successful management of the problem within their
organisation will rest on the following:

Early recognition of suspected cases and rapid isolation of the patient
concerned.
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
Absolute rigour in reducing the risk of cross infection through
effective respiratory precautions, high quality sterile practice by staff
caring for the patient concerned, exceptional standards of
environmental hygiene (e.g. walls, floors, surfaces) in the clinical
areas where patients have been cared for (even temporarily such as
accident and emergency departments), and absolutely no
inappropriate re-use of medical devices and equipment.

Giving the Hospital Infection Control Team a key role and if
necessary complete authority to remedy any vulnerability to cross
infection occurring.

Early involvement and the closest possible liaison with local public
health officials and with the national Health Protection Agency.
4. Chief Executives, their senior clinical and management teams and their
Boards should be aware that in other parts of the world serious outbreaks
have arisen because of transmission of SARS from a hospitalised patient or
one being transported by ambulance to health care workers, other
patients or visitors to the hospital.
5. The risk of transmission of SARS can be minimised if the correct
precautions are taken. That is why it is so important for Chief Executives,
clinical and all other staff to be aware of these routes of infection and the
meticulous handling necessary to reduce risk.
6. Precautionary action should commence:

In hospitals: as soon as a suspected or probable case is referred by a
general practitioner or NHS Direct or self-presents to an Accident and
Emergency Department or other clinical area.

In ambulance services: from first contact with a patient assessed to
be a suspect or probable case, throughout and after the journey to
hospital.

In primary care premises: from first contact with a patient who may
fit the case definition of suspect or probable SARS, particularly noting
the need for hygiene and decontamination in the clinical area in
which a patient has been assessed prior to urgent referral to
hospital.
7. NHS Chief Executives should meet with their senior teams urgently and
ensure that their current plans are adequate and that all staff are familiar
with them and understand what they should do should a suspect or
probable case of SARS be identified.
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8. There is a concern that health care staff recruited to the NHS from a SARS
affected country (or who have worked in a healthcare setting there) might
pose a risk to patients and other staff because of their higher risk of
exposure to SARS. Such health care staff (including students) should not
work in the NHS until 14 days after leaving a SARS affected country. If
during that time they develop symptoms compatible with SARS, they
should have clearance from a local public health official before starting or
returning to work. If any existing NHS staff have recently visited an
affected area for personal or professional reasons, they should be
excluded from work if they show any symptoms suggestive of SARS.
9. Detailed guidance and information necessary for local planning and
implementation is annexed to this letter as follows:
Annex A: Background information on SARS
Annex B: Diagnostic criteria and procedure for rapid reporting to local
public health officials and the Health Protection Agency
Annex C: Measures to be taken to minimise the risk of cross infection
Annex D: Arrangements for laboratory testing
Annex E:
Contact tracing and post hospital discharge monitoring
arrangements
Annex F: Question and Answer briefing on SARS
Annex G: Information for SARS contacts
Please note that downloadable guidance is available via the National Public
Health Service for Wales web site at: http://www.nphs.wales.nhs.uk. Links
are provided to the Health Protection Agency with updated information as it
becomes available.
Dr Mike Simmons
Senior Medical Officer (Communicable Diseases) on behalf of Dr Ruth Hall,
Chief Medical Officer
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Annex A:
Background information on SARS
Severe Acute Respiratory Syndrome (SARS) is the term used to describe a
new emerging disease which first appeared in Southern China in November
2002, has spread to other parts of East and South East Asia since February
2003 and has now been reported from 26 countries around the world.
It is a serious respiratory illness which may lead to severe pneumonia and
respiratory distress syndrome. Its main symptoms are high fever (>38° C),
flu-like symptoms, dry cough, shortness of breath or difficulty in breathing.
Chest X-rays changes indicative of pneumonia also occur.
Based on currently available evidence, close contact with an infected person
poses the highest risk of the infective agent spreading from one person to
another.
To date, many of the cases have occurred in hospital workers who have cared
for SARS patients and close family members of cases.
SARS appears to be less infectious than influenza. The incubation period is
believed to be short, around two to 10 days.
The reported global death rate for probable SARS cases is 4-10%.
The cause of SARS is considered by the World Health Organization (WHO) to
be “SARS coronavirus” (SARS CoV), a new member of the coronavirus family.
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Annex B: Diagnostic criteria and procedure for rapid reporting to
local public health officials and the Health Protection Agency (HPA).
Surveillance of SARS cases began on 17 March 2003 in the United Kingdom.
Case definitions
Initial case definitions provided by the World Health Organization (WHO) for
“suspect” and “probable” cases of SARS have been updated for the UK as
follows:
 Suspect cases in the United Kingdom have been sub-classified into
‘HIGH’ and ‘LOW’ categories (10 April 2003).
Suspect LOW case
A person presenting after 1 Feb 2003 with sudden onset of:
 high fever (>38°C)
And

cough or difficulty breathing

travelled in the 10 days before onset of illness to an area in which
there is more than 'limited' local transmission of SARS during the travel
period. As of 19 April 2003, the HPA considers these areas to be the
And
provinces of Beijing, Guangdong, Shanxi, and Hong Kong SAR in China,
Toronto, Hanoi, Singapore, and Taiwan. More information on currently
affected areas is available at the WHO website at
<http://www.who.int/csr/sarsareas/en/>.
Suspect HIGH case
A person presenting after 1 Feb 2003 with sudden onset of:
 high fever (>38°C)
And

cough or difficulty breathing

had close contact with a probable SARS case from an affected area in
the 10 days before onset of symptoms
And
Probable case
Either:
A suspect (Low or High) case with:
 chest x-ray findings of pneumonia and no response to standard
antimicrobial treatment
or

or
respiratory distress syndrome (RDS)
Death due to an unexplained respiratory illness with autopsy findings
demonstrating the findings of RDS without identifiable cause in a person who
travelled to an affected SARS area within 10 days of illness.
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Clinicians should be alert for people with illness conforming to the suspected
and probable SARS case definitions.
Suspected and probable cases should be reported through the local
Consultant in Communicable Disease Control (CCDC) to the Communicable
Disease Surveillance Centre (CDSC), Colindale at [email protected]. This
should be by telephone, fax or email followed up with the reporting form
available at <http://www.phls.org.uk/topics_az/SARS/sars_form_help.htm>
In addition, cases who fit the ‘probable’ case definition should be telephoned
through to the CDSC (out of hours to the duty doctor) on 020 8200 6868.
Information is available at the World Health Organization website on areas
within countries reporting foci of local transmission of SARS
at <http://www.who.int/csr/sarsareas/en/>.
!
ENSURE ALL YOUR
CLINICIANS ARE FAMILIAR
WITH CASE DEFINITIONS
!
MAKE SURE THAT YOU HAVE
UP TO DATE CONTACT DETAILS
(INCLUDING OUT OF HOURS)
FOR LOCAL PUBLIC HEALTH
TEAM AND NATIONAL HEALTH
PROTECTION AGENCY
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Annex C: Measures to be taken to minimise the risk of cross
infection.
Guidance for hospitals, other healthcare settings and ambulances on
the prevention of spread of SARS
The guidance given here is intended to supplement general infection control
guidance. In general, the guidance is that the precautions to control the
spread of SARS in health care settings should be those general infection
control measures taken against other respiratory infections that spread from
person-to-person, for example tuberculosis and influenza. Hospital staff
should refer to their infection control manuals and follow advice from their
hospital infection control teams. The guidance recognises that there have
been relatively few probable cases in the UK to date, and their illnesses have
been generally milder than in areas where most cases have occurred.
However, this cannot be assumed for future cases.
Where should patients who may have SARS be treated?
Patients who are defined as probable SARS cases (Annex B) are likely to
require hospital care for at least a few days. Many suspected cases in the UK
have not required admission to hospital because their symptoms were
relatively mild.
In hospital, patients with probable SARS should be nursed in a single room,
preferably with negative pressure ventilation. This applies even if they need
intensive care or assisted ventilation: such patients must not be treated on an
open unit.
The care of patients at home is described in a separate document at
<http://www.phls.org.uk/topics_az/SARS/gp_guidance.htm>.
What precautions should be taken in A& E departments?
Ideally, patients referred to hospital with probable SARS should be admitted
directly to a single hospital room without going via an A&E department, but
some patients who meet the case definitions of suspected or probable SARS
are likely to come to A&E departments. They should be identified rapidly at
triage and their stay there should be very short indeed - no protracted trolley
wait.
The initial assessment should include questions about fever, respiratory
symptoms, and recent travel as soon as possible after the patient arrives. The
most recent case definition for SARS (Annex B) should be used as a basis for
such screening questions. If the patient meets the definition of a suspect of
probable case, he or she should be put in a room or cubicle separate from
other patients while they are awaiting further assessment and a decision
whether to admit or send home. The infection control precautions of masks
and hygiene should be applied by staff attending patients with suspected or
probable SARS.
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What is the advice about masks when the patient is being assessed
or transported in an ambulance?
Patients with suspected SARS should be advised to cover the mouth and nose
with a handkerchief or tissue when coughing or sneezing. If possible, a SARS
patient should wear a surgical mask during close contact with uninfected
persons to prevent spread of infectious droplets. When a SARS patient is
unable to wear a surgical mask, healthcare workers should wear surgical
masks when in close contact with the patient. This applies to ambulance staff
if treating a patient at home or during transit. Surgical masks should be
changed every 4 hours.
What masks should health care workers wear when in close contact
with a patient with suspected or probable SARS?
A well-fitting disposable mask or respirator with filtering efficiency of the
European Standard EN 149:P2/FFP2 or the US standard of N-95 should be
worn where feasible. Where respirators are not available, healthcare
personnel assessing and caring for suspect SARS patients should wear a
surgical mask (changed very 4 hours).
What about care at home?
See separate document at
<http://www.phls.org.uk/topics_az/SARS/GP_guidance.htm>.
What about hand hygiene?
All people caring for a SARS patient should apply good hand hygiene (eg,
frequent hand washing or use of alcohol-based hand rubs), particularly after
contact with body fluids (eg respiratory secretions, urine, or faeces). Alcohol
hand rubs should only be used on visibly clean hands. Hands which are soiled
should be washed thoroughly. Disposable gloves should be worn for any
direct contact with body fluids of a SARS patient. However, gloves are not
intended to replace proper hand hygiene. Immediately after activities
involving contact with body fluids, gloves should be removed and discarded
and hands should be cleaned. Gloves must never be washed or reused.
Further information is at <www.doh.gov.uk/HAI>.
What about health care workers (HCWs) who develop (or might
develop) symptoms within ten days of contact with SARS cases?
In places with most SARS cases, several healthcare workers have developed
SARS after caring for infected patients with SARS. Personal protective
equipment appropriate for standard, contact, and airborne precautions (eg
hand hygiene, gown, gloves, and N95 respirator/mask) with, in addition,
eye protection, have been recommended for healthcare workers to prevent
transmission of SARS in healthcare settings. It is helpful if the hospital ward
and Occupational Health Department keeps a list of staff who have attended
a patient with probable SARS to facilitate the management of contacts.
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If a healthcare worker develops fever or respiratory symptoms during the ten
days following contact with a SARS patient, he or she should report their
illness as soon as possible to their GP or a designated hospital doctor
(according to local arrangements) and their occupational health service. They
should stay off duty until seven days after the resolution of fever and
respiratory symptoms. During this period, possibly infected workers should
avoid close contact with persons both in the hospital and in the general
community
How should staff who are in contact with a patient with probable or
highly suspected SARS be followed up?
Hospital staff who care for, or have direct contact with respiratory secretions
and/or body fluids of a person with SARS, will, by definition, be close
contacts.
Contacts are free to continue with usual activities unless they become unwell.
Any person who develops symptoms of SARS within 10 days of being a close
contact of a suspected case should be advised to seek medical advice and
inform medical staff of their contact with a suspected SARS case.
A list of staff who are close contacts, with the dates that they last had contact
with the case should be made. The staff close contacts should be contacted
to explain the follow up arrangements (which may be done by occupational
health, the hospital infection control team, the local CCDC / Health Protection
team or GP, depending on local agreements). The staff contacts should be
provided with information on SARS, and asked to report any fever or
respiratory symptoms. If the close contact develops symptoms consistent with
SARS they should be assessed at home following the earlier part of this
guidance.
On day ten following the last contact with the case, a check should be made
that any member of staff who was a close contact, and is now not at work,
has remained well.
How should healthcare workers returning from an affected area be
managed?
Healthcare staff who have visited affected areas should return to work as
normal, unless:
they are unwell and have symptoms consistent with SARS, in
which case they should stay off work and phone their GP for
assessment
or
they are well, but have been in close contact with a SARS case,
involved in the care of a SARS case, or worked in a healthcare
setting where cases were being treated. Healthcare staff in this
group should avoid contact with patients for fourteen days after
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departure from an affected area, contact their medical director
who in turn should liase with the CCDC for the area, and
monitor their own health for fourteen days, seeking medical
advice if they become unwell.
Hospital visiting
Family members of SARS patients are likely to fall into the definition of a close
contact and should be advised accordingly. Close contacts with either fever or
respiratory symptoms should not be allowed to enter the hospital as visitors
and should be educated about this policy. A system for assessing SARS close
contacts who are visitors to the patient in hospital for fever or respiratory
symptoms should be in place. Hospitals should educate all visitors about use
of infection control precautions when visiting SARS patients and their
responsibility for adherence to them, especially on hand washing on leaving
the patient's room. The hospital's policy on children visiting should be
followed.
What decontamination procedures should be used for equipment
and rooms used by patients with probable or highly suspected
SARS?
The hospital’s normal decontamination procedures, described in hospital
infection control manuals, should be followed but regular and meticulous
cleaning of clinical areas (surfaces, walls, door handles) should be
undertaken. Advice should be taken from the Hospital Infection Control Team
on detailed procedure.
What special precautions should be taken to decontaminate
ventilators used by patients with suspected or probable SARS?
The standard procedures for decontaminating ventilators should be sufficient
if the manufacturers’ guidance and hospital infection control manuals are
followed. Particular caution is required with nebulisers, which by creating an
aerosol may spread infection.
What is the guidance on post mortem examinations on people who
have died from suspected or probable SARS (as defined by the case
definitions)?
If a post-mortem examination is made on a patient who dies meeting the
case definition of a probable case, precautions should be taken against the
risk of infection from aerosols created during the examination. For autopsies
and postmortem assessment of SARS cases, personal protective equipment
(PPE) should include:
 Protective garments: surgical scrub suit, surgical cap, impervious gown
or apron with full sleeve coverage, face shield, shoe covers and double
surgical gloves with an interposed layer of cut-proof synthetic mesh
gloves.
 Respiratory protection: respirators to the US standard of N-95 or N-100
respirators; or powered air-purifying respirators (PAPR) equipped with
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a high efficiency particulate air (HEPA) filter. PAPR is recommended for
any procedures that result in mechanical generation of aerosols, eg use
of oscillating saws. Autopsy personnel who cannot wear N-95
respirators because of facial hair or other fit-limitations should wear
PAPR.
Safety procedures (which are standard) should include:
 prevention of percutaneous injury
 removing protective outer garments when leaving the immediate
autopsy area and discarding them in appropriate laundry or waste
receptacles, either in an antechamber to the autopsy suite or
immediately inside the entrance if an antechamber is not available.
 hand washing upon glove removal
The general precautions described in The infection hazards of human
cadavers (CDR Review Vol 5, No 5) should be followed. Embalming is not
advisable.
What precautions should be taken with laboratory specimens?
Blood and other specimens for routine biochemistry and haematology,
microbiology, or serology, may be handled using standard precautions. Details
should be found in the hospital infection control manuals. More information
on specimens is in the microbiology guidance at
<http://www.phls.org.uk/topics_az/SARS/clinical_guidance.htm>.
Copies of ‘The Management, Design and Operation of Microbiological
Containment Laboratories’, ISBN 0717620344, price £9.50, can be ordered
online at: http://www.hsebooks.co.uk or are available from HSE Books, PO
Box 1999, Sudbury, Suffolk, CO10 2WA, tel 01787-881165 or fax: 01787313995. Also visit www.hse.gov.uk/sars.htm for additional information.
Do SARS results change management?
Currently, laboratory tests for the new human coronavirus thought to be the
cause of SARS are still being refined.
A positive result from the specific SARS Coronavirus PCR means that the
patient with SARS has, or recently had, an infection with the SARS-associated
Coronavirus and this might have been the cause of SARS in this patient.
However, SARS is a clinical diagnosis. If a patient is tested negative for
SARS-associated coronavirus they should still adhere to isolation
precautions recommended for all patients with SARS.
Source of information
Based on discussions within the Health Protection Agency team and with
other colleagues on standard infection control procedures and on SARS
guidance published by Centers for Disease Control and Prevention (CDC),
Health Canada and the World Health Organization.
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Further information is available on the website of the former PHLS at
<http://www.phls.org.uk/topics_az/SARS/health_professional_page.htm>.
!
CLOSELY INVOLVE YOUR
HOSPITAL CONTROL OF
INFECTION TEAM
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Annex D: Arrangements for laboratory testing
Guidance on microbiological sampling and investigation of cases of
SARS
Please note that this is a rapidly evolving situation, with new information
becoming available daily. Up to date information is on the HPA web site.
Please share these notes with colleagues as appropriate, and ensure that your
local microbiology laboratory staff are prepared to deal with enquiries from
GPs, hospital clinicians and public health doctors.
Sending samples from SARS cases to national reference laboratory
Clinicians who suspect SARS should first contact the Respiratory Division of
CDSC (020 8200 6868) and fax a completed SARS report form, available at
<http://www.phls.org.uk/topics_az/SARS/Questionnaire2103.doc>.
Once a form has been sent, then appropriate samples should be sent to the
Influenza Laboratory. A guide to the samples required is listed below. If it is
uncertain whether samples should be sent to the reference laboratory ie a
returned traveller not fulfilling all case definition criteria, the case should be
discussed with the influenza laboratory.
The laboratory address is the Influenza laboratory, ERNVL, SRM, 61 Colindale
Avenue, Colindale, London NW9 5HT.
Samples required
Mild illness (including possible or unlikely cases); paired sera (dilute and
convalescent [day 21]) only are required.
Moderate and severe illness (more likely seen in probable cases in hospital) a
full complement of specimens are required as listed below. These will be
required daily in ill symptomatic cases and in ALL probable cases. Apart from
serum samples, the influenza reference laboratory should be contacted for
other samples sent.
Respiratory samples: preferably nasopharyngeal aspirate (taken by someone
experienced in the technique). Nasal washings or nose and throat swabs
acceptable.
Blood: Acute and convalescent serum (20 mls clotted whole blood) and 20
mls EDTA blood.
Urine: 20-30mls
Stool sample
Conjunctival swab
All samples should be couriered as soon as possible on wet ice. Hays DX
entails overnight delay and is not recommended (except for sending sera
from mildly unwell patients for purposes of retrospective serology).
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Significant results will be discussed with the referring microbiologist or
clinician as soon as possible by telephone. If clinical material arrives from
individuals where CDSC have not been notified by telephone or fax, analysis
may be delayed. Samples must be clearly marked SARS, high risk for the
attention of Dr Zambon, Influenza laboratory, SRM on the outside of the
packaging. Full patient and travel details should be supplied as well as contact
details, including a telephone number, for the referring clinician.
Sampling Cases in Primary Care
GPs should make an initial assessment as to clinical severity. If it is
considered that the case requires hospital referral on clinical grounds, alert
the receiving physicians and the infection control team to the possibility of a
case of SARS. If it is considered that the illness is mild/resolving/does not
require hospitalisation, GPs are asked to discuss cases with their local
CCDCs/microbiologists.
Mild cases managed at home should have acute and convalescent (day 21)
blood serum samples taken. Samples should be sent to Colindale once CDSC
has been contacted and a form sent.
Sampling Hospital Cases
Sampling should be according to local protocols for investigation of
pneumonia/severe respiratory infection with particular attention paid to the
following aspects:
Comprehensive microbiological investigation. Results from local microbiology
testing strategy are essential so that cases where known pathogens are
identified can be removed from the probable, suspect and possible case lists.
Laboratory handling and containment of samples.
It is suggested that samples taken from hospitalised cases of probable and
suspect SARS are handled at Containment Level 3. If the local laboratory does
not have operational containment level 3 facilities then such samples should
be forwarded directly to either a nearby laboratory with appropriate facilities.
Where an illness is retrospectively identified as probable or suspect SARS, any
remaining samples should be transferred to containment level 3 facilities.
After reviewing existing results and available samples, further local
investigation and/or transfer of material to national reference laboratories
may be indicated. See notes below regarding the handling of nonmicrobiology investigations.
Preservation and splitting of samples.
Every precaution should be taken to preserve material and store at -70ºC
prior to transport to national reference labs, preferably by courier, for
investigation of unknown viral and bacterial agents.
Isolates
Simple tests to determine the likely identity of the isolates may be carried out.
If it is not possible to confidently identify any bacterial organism as a known
15
‘non pathogen‘ antimicrobial susceptibility tests should be set up and the
isolate referred on to the appropriate national reference laboratory.
Interpreting any isolate, bacterial or viral as ‘not significant’ in the current
context should only be done with caution. All isolates cultured from these
patients should be retained locally for possible subsequent examination.
Advice for laboratory workers
It is recommended that all clinical samples received from PROBABLE AND
SUSPECT case patients and cultures/material derived from those samples
should be handled at Containment Level 3 (CL3) until further evidence and
advice allow alternatives. Where this presents difficulties, a local risk
assessment should be made on a case by case basis. The CDSC case status
designation can be used as a guide, PROBABLE AND SUSPECT cases require
CL3.
Clinical Sample Handling
Respiratory samples
It is anticipated that appropriate diagnostic microbiology for the investigation
of atypical pneumonia will be performed local to the case presentation. A
broad diagnostic virology strategy, including virus isolation in a range of
permissible cell lines is recommended which would capture human influenza
viruses, adenoviruses, respiratory syncytial virus, parainfluenza viruses,
enteroviruses and human metapneumovirus present in respiratory secretions.
Suggested combinations of cell lines include a primary monkey
kidney/fibroblast/mammalian epithelial cell line.
The best respiratory samples for virus detection are samples which include
respiratory epithelial cells as well as respiratory secretions. In practice, these
would be obtained by nasopharyngeal aspirates, nasal washes or combined
nose and throat swabs, taken into virus transport medium which does not
contain bovine calf serum. Bronchoalveolar lavage or endotracheal aspirates
are also suitable samples.
A broad diagnostic bacteriology screen to include typical and atypical bacteria,
especially chlamydia, mycoplasma and legionella is also recommended.
Sputum is not a suitable sample for virology but is appropriate for bacterial
investigations, which will also need to be undertaken consider extending
incubation if no significant isolates after standard interval. Please retain
portions of sample at -70ºC or lowest temperature available.
Blood
Acute serum samples: at least 20mls taken into plain tubes. Serum should be
separated with precautions appropriate for HIV/hepatitis or other blood borne
virus transmission. (Convalescent serology should be collected 21 days
later.)
16
Blood cultures: Automated systems should detect most, if not all bacterial
agents however if negative after your standard interval consider extending
incubation. Please retain negative bottles for possible subsequent examination
by PCR or other testing methods. Negative blood culture bottles should be
aliquoted into 3x1ml containers and stored at or below -20ºC.
Urine
MSU or CSU or clean catch collection of at least 20 mls into sterile container
should be examined according to local protocols and as clinically indicated.
Legionella and pneumococcal antigen detection should be considered. Store
remainder for possible subsequent examination at -70ºC or lowest
temperature available.
Other samples for clinical microbiology
If cerebrospinal fluid, pleural fluid, pericardial fluid, or any other specimens
are taken as part of the clinical diagnostic workup, culture as routine,
consider extending incubation if negative after your standard interval and
retain any isolates obtained. Reserve a portion of the sample at -70ºC or
lowest temperature available.
Non-microbiology clinical samples eg haematology and biochemistry
Samples can be processed in the local laboratory, samples from PROBABLE
OR SUSPECT cases should be treated as “high risk”. Blood should be handled
with precautions appropriate for HIV/hepatitis or other blood borne virus
transmission.
How to interpret SARS test results
Laboratory results strongly suggest that coronavirus has a role in SARS. A
new coronavirus, known as SARS-associated Coronavirus (SCV) has been
identified as a possible cause of SARS however other viruses are still under
investigation as potential causes. Currently, laboratory tests for the new
human coronavirus are still being refined.
A positive result from the specific SARS Coronavirus PCR means that the
patient with SARS has, or recently had, an infection with the SARS-associated
Coronavirus and this might have been the cause of SARS in this patient.
SARS is a clinical diagnosis.
If a patient is tested negative for SARS-associated coronavirus they should
still adhere to isolation precautions recommended for all patients with SARS.
More detailed information on interpreting SARS test results is available at
<http://www.phls.org.uk/topics_az/SARS/result_interpretation.ht
m>
The Influenza Laboratory SRM will coordinate the investigation of samples
subsequent to local microbiological examination from PROBABLE OR SUSPECT
UK cases of SARS. Investigation of cases can be discussed with Dr Maria
Zambon or Dr Paul Simons (virology) via the SRM or CDSC duty doctor if
required.
17
!
CLOSELY INVOLVE YOUR
CONSULTANT
MICROBIOLOGIST
18
Annex E: Contact tracing and post hospital discharge monitoring
arrangements.
Follow-up of cases
In order to provide information on the outcome of illness of cases and the
current level of public health risk from SARS in the UK, the following follow-up
categories of suspected and probable SARS cases are used:
Follow-up categories
1. Still ill
2. Recovered = afebrile for at least 48 hours AND cough, if present,
resolving
3. Dead
In addition, any results of other diagnoses should be provided at follow-up.
New follow-up procedures from 12 April 2003
Follow-up of suspect or probable cases of SARS will be coordinated by
regional epidemiologists.
On receipt of an initial report (either by fax, email or phone), the SARS team
at CDSC will log the call and/or report into the SARS database and define the
patient according to the UK SARS case classification. Reports of patients who
do not fit the case definition will be kept on file but will not be followed-up.
Reports of patients classified as a suspect (low or high) or probable case will
be faxed or emailed to the regional epidemiologist (RE) on the same day of
notification. Follow-up of patients should be initiated by the RE or CCDC using
the standard form available at
<http://www.phls.org.uk/topics_az/SARS/sars_form_help.htm>.
Progress follow-up forms should be faxed or emailed to CDSC:
 48 hours after the date of report
 ten days after the date of report and/or
 A final follow-upform once the patient is asymptomatic
Contacts of cases
 Close contacts are considered to be family, friends or health care
workers who lived with, cared for or who had direct contact with
respiratory secretions and/or body fluids of a person with SARS.
 Any person who develops symptoms of SARS within 10 days of being a
close contact of a suspected case should be advised to seek medical
advice and inform medical staff of their contact with a suspected SARS
case.
 Inform the contact they are free to continue with usual activities unless
they become unwell.
Management of close contacts of probable and highly suspect cases

Generate a list of such contacts and record the date on which they last
had contact with the case
19




Liaise with the local CCDC / Health Protection team on follow-up
responsibilities
On day one, the GP or local Health Protection Team should telephone
the contact to assess their health and provide them with information
on SARS, available at
<http://www.phls.org.uk/topics_az/SARS/case_contacts.pdf> and
<http://www.phls.org.uk/topics_az/SARS/FAQs.htm>
On day ten following last contact with the case the GP or local Health
Protection Team should telephone the contact to assess their health.
If the contact develops symptoms consistent with SARS they should be
assessed at home following the earlier part of this guidance.
Management of close contacts of low suspect cases


Give information on SARS to the contact
No specific follow-up is needed for contacts of low suspect cases
Management of other contacts
Occasionally it may be necessary to inform other people (eg airline
passengers or work colleagues) who have been in contact with a symptomatic
case of SARS. They should be advised to seek medical advice if they develop
symptoms of respiratory illness within ten days of contact with a suspected
SARS case and inform medical staff of their contact. Investigation should be
carried out as for other suspected cases.
Health alert notices for contacts of probable or suspected SARS
cases <http://www.phls.org.uk/topics_az/SARS/case_contacts.pdf> and
travelers <http://www.phls.org.uk/topics_az/SARS/traveller_health_alert.pdf>
are available on the website of the former PHLS as PDF files for printing and
distributing in airline lounges, GP waiting rooms etc. These are also at Annex
G.
!
LIAISE CLOSELY WITH LOCAL
PUBLIC HEALTH TEAMS AND
SEEK THEIR ADVICE IF IN
DOUBT
20
Annex F: Question and Answer briefing on SARS.
Frequently asked questions about Severe Acute Respiratory
Syndrome
Q
A
What is Severe Acute Respiratory Syndrome (SARS)?
SARS is the term being used to describe a serious respiratory
illness which has recently been reported in parts of east and
south east Asia, and in Toronto, Canada.
Q
A
What are the symptoms of SARS?
The main symptoms of SARS are high fever (>38° C), dry
cough, shortness of breath, or breathing difficulties. Changes in
chest X-rays indicative of pneumonia also occur.
Q
A
How contagious is SARS?
Based on currently available evidence, close contact with an
infected person poses the highest risk of the infective agent to
spread from one person to another. To date, the majority of
cases have occurred in hospital workers who have cared for
SARS patients and the close family members of these patients.
Q
A
What is the treatment for SARS?
There is no specific treatment.
Q
A
How fast does SARS spread?
SARS appears to be less infectious than influenza. The
incubation period is believed to be short, around 2 to 10 days.
The speed of international travel does, however, create a risk
that cases can rapidly spread around the world.
Q
A
What can I do to protect myself?
Only a few cases have been identified outside of South East
Asia and these cases were in people who had travelled from
there, mainly in Canada. The best advice is to be aware of the
symptoms of this illness, particularly if you have recently
travelled in Hong Kong, Singapore, Vietnam, Taiwan, Beijing,
Guangdong China and other parts of south east Asia, and seek
medical advice should you develop them within ten days of your
return.
Q
A
Is there a vaccine for this?
No, a vaccine is not available as this is a new emerging
pathogen.
Q
A
How many cases of SARS have been reported to date?
For the latest number reported cases worldwide, please refer to
21
the WHO website at <http://www.who.int/csr/sars/en/>. For
the latest number of cases reported in the UK, please refer to
the website of the former PHLS at
<http://www.phls.co.uk/topics_az/sars/menu.htm>.
Q
A
Could this result from bioterrorism?
There is no indication that SARS is linked to bioterrorism.
Q
What should I do if I am planning to travel to Hong
Kong, Toronto, Singapore, Thailand, Vietnam, China, or
other areas in South East Asia?
Travellers to South East Asia need to be aware of these
outbreaks and take them into account in their travel plans.
Latest information is available on the FCO website at
<http://www.fco.gov.uk>, and the travel section of the WHO
website at <http://www.who.int/health_topics/travel/en/>.
A
Q
A
Q
A
Q
A
What should I do if I have recently returned from South
East Asia and feel unwell?
If you have recently returned from South East Asia and suffer
from any of the following symptoms: sudden onset of fever
(>38° C), together with respiratory symptoms such as cough,
sore throat, shortness of breath or difficulty breathing within 10
days of return, please contact your GP surgery or phone NHS
Direct on 0845 4647.
I've heard of cases of SARS in England – can you
confirm this?
There have been suspected cases of SARS reported in the
media, however we will only be reporting cases that are
probable and therefore fit the case definition issued by the
WHO. At this time of year in south-east Asia influenza activity is
high and we would therefore expect travellers to this area to be
returning with flu-like symptoms, which are unrelated to the
current outbreaks of SARS. As there is no specific cause for
SARS and no specific organism that we can test for to diagnose
cases, each suspected case has to be evaluated on the clinical
presentation of its symptoms.
Why are you not screening people as they come off
aircraft into the UK?
Screening is now taking place at the airports where passengers
are leaving in the places where transmission has been reported
to be taking place, such as Hong Kong and southern China. This
screening includes passengers completing a form on entry and
being asked questions about any ill health on their departure.
This reduces the risk of exposure to other passengers on
flights. As we don’t have ongoing transmission in this country,
22
as they do in Hong Kong and southern China, it hasn’t been
necessary to impose such measures here.
Q
A
What do you do if somebody is sick on a plane?
WHO has provided guidance for this to airlines which is
available through the WHO website. This is not new - it has
always been accepted that if people get ill on an aircraft, they
are looked after and the crew are trained on how to do this.
Port Health Authorities are forewarned that there is an ill
passenger and make the necessary arrangements to look after
them when they arrive at the airport. If it is felt necessary,
other passengers on the plane will be alerted about any incident
and advised to look out for the symptoms and seek medical
advice if they develop these symptoms within 10 days of their
return.
Q
A
Why are you so worried about this infection?
It is important to keep the risk in proportion. Even though there
have been many people that we have looked at because they
have come back from Hong Kong and have had a temperature
and a cough, in fact there have only a handful of probable
cases – and when you compare this to the amount of people
coming back from Hong Kong each day the risk is very low.
However, SARS can be a very serious condition. Not all people
suffering from SARS have developed pneumonia, but in those
who have the risk of dying is about 1 in 30. Also, as we have
seen in Canada, if the infection gets into a hospital, it can
spread very quickly. Therefore, the Chief Medical Officer has
made sure that everybody in the Health Service is aware of the
risk and what to do if they believe they have a case.
Q
A
Do you know what's causing this infection?
Eleven laboratories in a World Health Organization network,
including the Health Protection Agency’s Specailist abd
reference microbiology laboratoryhave identified a particular
strain of corona virus that is unlike any other corona virus
infecting humans. The nature of the corona virus remains to be
determined, as we only have very limited information about it
so far. We still can’t categorically say it has caused SARS,
although it has been found in a high proportion of cases
worldwide and it is therefore referred to as a ‘SARS associated
corona virus’. We have to keep an open mind that there may be
other agents involved in causing SARS.
Q
A
Is there a test for SARS?
Work is going on worldwide to develop tests.
Q
I’ve heard of people being put in quarantine if they are
23
A
Q
A
Q
A
Q
A
suspected of having SARS, or have been to areas
affected by SARS – is this really necessary?
In parts of south east Asia, people have been put in quarantine
to prevent the spread to others and this is a measure taken by
the local health authorities who are handling the situation. The
situation in this country is different as there is no evidence of
local transmission of SARS here.
I came back from Hong Kong (or another area affected
by SARS) a week ago and I have now got a temperature
and a bit of a cold. What should I do?
A lot of people in this situation have been reported to us and so
far, almost of all them have simply had a cold, or another
common respiratory illness. However, because of the risk of
SARS, we are recommending that anyone developing a fever
and either a cough or difficulty in breathing, go home and
consult their GP by phone or call NHS Direct (0845 46 47). If
you have to go to hospital, it will be important that you let the
hospital know when you get there that you have recently been
to an area affected by SARS or had contact with somebody with
SARS. It may help if you print out this paper and show it to
them.
Is it true that a lot of people in this country could be
affected by SARS?
We are unable to say how the current worldwide situation will
evolve and if the current outbreaks have reached a peak or if
cases will continue to increase. We are confident that we have
strong surveillance systems in place in the UK to identify any
returning travellers who may be suspected as having SARS.
Through this surveillance we have picked up a handful of
probable cases in England, and the first three of these have all
recovered and been discharged from hospital. We have issued
advice to health professionals in the UK to be alert to any
returning travellers with symptoms of SARS and have also
issued advice to travellers themselves to be aware of the
symptoms. We have good infection control measures in place in
hospitals in this country and have issued advice for health care
professionals caring for any cases to prevent any further spread
of SARS.
You say that SARS is transmitted by close contact, so
what has been happening in the tower block in Hong
Kong where lots of people have contracted SARS?
To date the information we have on transmission of SARS has
shown that almost all cases have occurred in close contacts,
such as health care workers, or close household contacts. In a
small number of cases there is the possibility that another route
24
of transmission may have been involved and this is being
investigated by health authorities in Hong Kong. We are
watching the worldwide situation closely and keeping in contact
with the WHO.
Q
A
Q
A
Q
A
Q
A
What about children in Hong Kong and other affected
SARS areas who are returning to the UK where they
attend a boarding school?
Children are no different from other returnees to the UK from
SARS affected areas. Their risk is low (most cases of SARS have
been in adults and in those with direct contact with SARS cases
over a prolonged period) and as with other returnees should be
advised to seek medical attention if they develop any symptoms
suggestive of SARS.
What about any risk to other children in a boarding
school?
Many schools are advising parents that their children should
return to the UK 10 days before the start of the new term in
order for them to check their health over the period when
symptoms might occur. By doing this, they state that disruption
to school activities will be kept to a minimum. We are not
making this recommendation and are not treating children any
differently to other returnees from SARS affected areas.
Can people return to work after visiting a SARS affected
area?
People who have visited SARS affected areas may return to
work and continue with their normal activiies as long as they
are well. If they are unwell and have any of the following
symptoms – fever, cough, difficulty breathing – they should
stay off work and phone they GP for assessment.
Even people who have been in contact with a case of SARS can
return to work, unless they have symptoms. These individuals
should, however, monito their own health closely for ten days
and phone their GP immediately if they have any of the
symptoms listed above.
Further information on SARS (including health alert noties for
travellers and contacts of cases) is available at
<http://www.phls.org.uk/topics_az/SARS/public_page.htm>
Can healthcare staff return to work after visiting a SARS
affected area
Healthcare staff who have visited an affected area should
return to work as normal,
unless:
they are unwell and have symptoms consistent
25
with SARS, in which case they should stay off
work and phone their GP for assessment
or
they are well, but have been in close contact with
a SARS case, involved in the care of a SARS case,
or worked in a healthcare setting where cases
were being treated. Healthcare staff in this group
should avoid contact with patients for fourteen
days after departure from an affected area,
contact their local medical director or occupational
health department, and monitor their own health
for fourteen days, seeking medical advice if they
become unwell.
26
Annex G: Information for contacts.
Information for contacts can be downloaded and given to them.
Visit
< http://www.phls.org.uk/topics_az/SARS/case_contacts.pdf>
Leaflets for contacts can also be obtained from
<www.immunisation.org.uk/sars.htm>
The wording of the leaflets is attached.
27
DEPARTMENT OF HEALTH
INFORMATION FOR CONTACTS OF CASES OF Severe
Acute
Respiratory Syndrome (SARS)
TO THE CONTACT
You have been given this leaflet because you may have had contact with a possible case of severe acute
respiratory syndrome (SARS).
Most cases of SARS have occurred after close contact with a patient with SARS (close contact includes
having cared for, having lived with, or having had direct contact with respiratory secretions and/or
body fluids of a person with SARS). As a precaution, it is recommended that you monitor your health
for ten days.
If you become unwell with a flu-like illness including
• high fever and cough
• shortness of breath or
• difficulty breathing,
you should seek medical attention. If you are in the UK see your GP or call NHS Direct on
0845 46 47
Please save this leaflet and give it to your doctor if you become ill and inform him or her of your
contact with a case of SARS
TO THE DOCTOR
The patient presenting this leaflet may have been in contact with a case of severe acute respiratory
syndrome (SARS).
Please notify your local Consultant in Communicable Disease Control immediately if your patient has
the following symptoms:
• high fever (>38°C)
• one or more respiratory
symptoms
including
• cough
• shortness of breath
or
• difficulty in breathing
The causative organism had not been confirmed to date.
Information about the identification, management and reporting of suspected SARS in the UK, is
available from the website of the former Public Health Laboratory Service at www.phls.org.uk
Alternatively, global updates on the SARS situation are available from the World Health Organization
website at www.who.int/csr/don/en/