Outbreak preparedness & control PPHSN Guidelines For the Preparedness, Surveillance And Response To Severe Acute Respiratory Syndrome (SARS) in Pacific Island Countries And Territories April 9th 2003 SARS is a new disease syndrome. Our knowledge about the best way to prevent and treat it is constantly evolving. These guidelines will be continuously updated. Please regularly check PPHSN website for the most up to date guidance. These guidelines have also been ‘harmonised’ with the WHO WPRO guidelines published on 4th April. BASIC DISEASE FACTS (Updated 09.04.03) Background As of 08 April 2003, reports of over 2671 cases, including 103 deaths, of Severe Acute Respiratory Syndrome (SARS), an atypical pneumonia of unknown aetiology, have been received by the World Health Organization (WHO) since 16 November 2002. WHO is coordinating the international investigation of this outbreak and is working closely with health authorities in the affected countries to provide epidemiological, clinical and logistical support as required. SARS was first recognised on the 26 February 2003 in Hanoi, Viet Nam, but the epidemic started in Guangdong in November 2002. Local transmission occurred in the following areas: Guangdong and Shanxi provinces and the Special Administrative Region of Hong Kong in China, Taiwan in China, Hanoi in Vietnam, Singapore and Toronto in Canada. Only imported cases were reported in 13 other countries. It is currently agreed that a new coronavirus ("SARS virus") is the major causative agent of SARS. The main symptoms and signs include high fever (>38 degrees Celsius), cough, shortness of breath or breathing difficulties. Approximately 10 percent of patients with SARS develop severe pneumonia; about half of these have needed ventilator support. As of 09 April the majority of cases have occurred in people who have had very close contact with other cases; for this reason, health care workers are at particular risk. Description of disease The syndrome begins with fever for 1-2 days, then a dry cough or dyspnea for 2-3 days. Atypical pneumonia develops on day 4-5 in the majority of cases. It is initially unilateral but after a further 1-3 days it often becomes bilateral, progressing to extensive "white-out" on chest XRay. The disease then takes 1 of 2 courses: A) the patient improves (80-90% of cases) and recovers over the next 4-7 days; or B) the patient deteriorates severely on day 6-7 with respiratory distress (10-20% of cases). 50% of patients in category B require mechanical ventilation. The mortality rate in this sub-group is high. During the early phase of the outbreak, around 50% of type B cases have died, giving an overall CFR of 5-10%. Risk factors for poor outcome are not clear, apart from the severity of illness and the need for mechanical ventilation. So far SARS has affected predominantly adults aged 20-70 yrs. Very few cases have occurred in children. All modes of transmission have yet to be determined. Aerosol and/or droplet spread is likely as is transmission from body fluids. Respiratory isolation, strict respiratory and mucosal barrier nursing are recommended for cases. Cases should be treated as clinically indicated. (see below for further details). Epidemiology Agent and infectious dose The search has been progressively narrowed to members of the paramyxovirus and coronavirus families, and it is currently agreed that a new coronavirus, "SARS virus", is the major causative agent of SARS. The infectious dose is unknown. Source From the knowledge available to date the source of an infection is another person who is ill with SARS. Occurrence So far all cases reported from outside the affected areas have a history of travel in the previous 10 days through an affected area OR close contact with a case of SARS. Mode of transmission The agent is spread from person to person through respiratory droplets and contact (including fomites). Airborne transmission appears uncommon if it occurs at all and transmission through environmental factors is being investigated. Period of communicability Not known but particularly infectious once respiratory symptoms appear. A lower risk of transmission is likely to be present during the prodromal phase (see figure 1). Incubation period The incubation period is thought to be 2-7 days exceptionally 10 days, most commonly 3-5 days Vulnerable population sub-groups Health care workers and immediate family members and friends of SARS cases are at extreme risk of becoming a case. Secondary cases from air travel are reported. Insufficient information available at this stage about who is at risk to become severe ill and die. But probably worse outcomes can be expected in individuals with underlying respiratory and cardiac illnesses such as asthma, COPD and heart disease. Risk in the Pacific The main risk in the Pacific is the importation of cases from affected areas with subsequent local transmission to close contacts including health workers. >> Figure 1: Clinical picture in SARS patients | 
