HEALTH AND SAFETY GUIDE

ANGELO ACQUISTA, M.D.

Author of The Survival Guide: What to Do in a

Disclaimer: The information here is intended to be used only as a reference tool. It is not meant

to replace the professional advice and expertise of your physician, or to encourage patients to

evaluate the risks and benefits of using certain medications without consulting their healthcare

providers. Only a physician can make accurate diagnoses, choose the best treatment for you, as well

as prescribe medication, advise of possible drug interactions, and monitor and evaluate a patient’s

response and reaction to medications. Protective equipment and tactics are also for informational

purposes only; persons must listen to authorized personnel for updates and instructions. Neither the

Apple Care Foundation nor their affiliates advocate the use of any of the medications mentioned in

this article, nor do they warrant the safety or efficacy of any medications, nor of any protective

equipment or strategies or decontamination procedures listed herein.

Copyright © 2003 by Apple Care Foundation

Our sincere thanks to Arthur H. Tinkelenberg, Ph.D.,

Evan Bell, M.D., and Laurie A. Vandermolen for the research and

writing of this article on behalf of the Apple Care Foundation.

SARS

Severe Acute Respiratory Syndrome (SARS)

Previously unknown species of coronavirus Virus

Close person-to-person contact via respiratory aerosol; touching contaminated surfaces such as

door knobs, hand rails, and elevator buttons, then touching your eyes, nose, or mouth; reports

suggest it may also be spread through ventilation systems, plumbing, and by rats and cockroaches

Typically 2Š7 days, possibly up to 10 days

Fever (greater than 100.4°F); other symptoms may include chills, headache, general feeling of

discomfort or body aches; possibly mild respiratory symptoms at the outset; after 3Š7 days, patients

may develop a dry cough and progressively worsening shortness of breath

Š Wash hands on regular basis as preventative measure

Š Consult your doctor if experiencing fever >100.4°F accompanied by cough or difficulty breathing

Š Adhere to travel advisories and quarantine as instructed by authorities

Š Patients are considered to be infectious for 10 days after fever and respiratory symptoms are gone

Š Patient should restrict interaction outside the home and not go to work, school, etc. for the 10-

day period

Š Patient should cover mouth and nose when sneezing or coughing with a tissue or wear an N95

respiratory mask; if patient unable to wear mask, household members should wear them

Š Disposable gloves should be worn if contacting patient body fluids; throw away when finished

and wash hands

Š Avoid sharing eating/drinking utensils and linens; wash these items thoroughly with soap and

hot water after patient’s use

Š Disinfect toilets, sinks, and other surfaces touched by patient with household disinfectants

frequently

None; antiviral drugs currently being tested

Estimated to be 5 - 6%

None

Severe Acute

Respiratory Syndrome

Severe Acute Respiratory Syndrome

(SARS) is an atypical pneumonia that

investigators believe is caused by a

previously unknown species of

coronavirus. In late 2002 cases of a

life-threatening respiratory disease

with no identifiable cause were

reported from Guangdong Province,

China, many of which can be linked to

a single healthcare worker from there

who visited Hong Kong and then died

of the disease there. By April 2003 the

disease had spread to 26 countries,

including the United States.

Coronaviruses are a frequent cause of mild to moderate upper-respiratory illnesses (such as

the common cold) in humans and are also associated with sometimes severe respiratory,

gastrointestinal, liver, and neurological disease in animals. Presumably the SARS-related

coronavirus originated in animals and mutated or recombined in a fashion that permitted

it to pass from person-to-person. It appears that this virus may be the first example of a

coronavirus that causes severe disease in humans; while it apparently has low infectivity

(meaning a large dose is required to pass the infection on to a recipient), it is highly

virulent (that is, extremely toxic to a patient).

The discovery and description of this new virus within a matter of months occurred

through a broad-based and multidisciplinary effort by clinical, epidemiologic, and

laboratory investigators from around the world. This approach shows the power of a global

collaborative effort to address the threat of emerging infectious diseases.

Changes in society, technology, environment, and microorganisms may all contribute to

the emergence of novel disease outbreaks, changes in host susceptibility, and the evolution

of drug-resistant microorganisms. Candidate factors affecting the emergence of SARS

include human demographics and behavior, human susceptibility to infection, economic

development and land use, changing ecosystems, international travel and commerce,

microbial adaptation and change, breakdown of public health measures, and others as yet

to be determined.

Studies of patients who have died of SARS show damage to the tiny air sacs (alveoli) within

the lungs as the most notable feature. In some patients, the lung lesions were similar to

lung injury (known as adult respiratory distress syndrome) caused by infections, trauma,

drugs, or toxic chemicals. When lung tissue is damaged to this degree, the amount of

oxygen in a person’s blood is compromised. If damage is severe enough, the patient can die

from the lack of oxygen.

The primary way that SARS appears to spread is by close person-to-person contact. Most

cases of SARS have involved people who cared for or lived with someone with SARS, or

had direct contact with infectious material (for example, respiratory secretions) from a

person who had SARS. Potential ways in which SARS can be spread include touching the

skin of other people or objects that are contaminated with infectious droplets and then

touching your eyes, nose, or mouth. This can happen when someone who is sick with

SARS coughs or sneezes droplets onto themselves, other people, or nearby surfaces.

Information to date suggests that people are most likely to be infectious when they have

symptoms, such as fever or cough. However, it is not known how long before or after their

symptoms begin that patients with SARS might be able to transmit the disease to others.

Currently, the recommended period to maintain precautions around infected patients is

10 days after their symptoms have stopped.

It is also possible that SARS can be spread more broadly through the air or by other ways

that are currently not known. It has been reported that it may be spread through

ventilation systems, plumbing, and by rats and cockroaches.

Because patients of SARS seem to be either healthcare workers taking care of sick people

or contacts of patients—a pattern of transmission that would typically be expected in a

contagious respiratory or flulike illness—it does not appear that the dissemination of

SARS is related to bioterrorism.

While 90% of cases will be mild, around 10% of patients will require intensive care

therapy. The estimated mortality rate is currently 5Š6%, which is more than double the

rate of early cases. By comparison, the mortality rate during the Spanish flu pandemic of

1918Š19 was around 1Š2.5% and killed 20Š50 million people worldwide. The high death

rate in that outbreak has been attributed to the virulence of that particular virus and to its

spread around the world. Given the high rate of modern travel and the fact that there

remains no effective therapy for influenza viruses, these parallels are of major concern.

How long the virus can survive outside of the body has tremendous epidemiological

consequences. In general, enveloped viruses such as coronaviruses do not last a long time

in the environment. However, in a preliminary study, researchers found that both dried

and liquid samples of the new coronavirus survived as long as 24 hours. Additional studies

are underway to examine this question.

Š Persons with close contact with infected individual

Š Persons traveling to outbreak areas

Š Close family members of patients (caretakers/attendants)

Š Persons admitted to hospitals where SARS patients are in residence

Š Persons who visit hospitals where SARS has been recognized

Š For all of the above, particularly persons with underlying health conditions

As of April 25, 2003, 18 suspected cases of SARS have been reported in New York City.

Of those, 17 were mild cases (typically just fever and cough), 1 was hospitalized, and all

patients are improving. Residents potentially having SARS had onset of symptoms during

travel or shortly after return from countries with known community outbreaks. A

spokesperson for the NYC Department of Health and Mental Hygiene has said that it

would not be unexpected if more local transmission followed given the close-quartered

conditions and travel climate of New York. The Department has been monitoring cases

and their household contacts for 10 days after the SARS patients have recovered.

The time from exposure to the initiation of symptoms is typically 2Š7 days, however, some

reports have suggested a time period as long as 10 days. Illness begins with a fever and

flulike symptoms. After 3Š7 days, a lower respiratory phase begins with the onset of a dry

cough and/or shortness of breath. The severity of illness is highly variable, ranging from

mild illness to death. In most patients, health improves in 2Š3 weeks. In severe cases, death

may occur after 1 week from the onset of symptoms.

The illness generally begins with a fever (greater than 100.4°F) that is sometimes

associated with chills and stiffness, and might be accompanied by other symptoms,

including headache, general feeling of discomfort, body aches, and diarrhea. Typically, rash

and neurologic or gastrointestinal findings are not found. At the onset of illness, some

persons have mild respiratory symptoms. After 3Š7 days, SARS patients may develop a

dry, nonproductive cough that might be accompanied by shortness of breath, which may

progress to respiratory failure.

If you are ill with a fever greater than 100.4°F that is accompanied by a cough or difficulty

breathing, you should consult a doctor. To help your doctor make a diagnosis, tell him or

her about any recent travel to regions where cases of SARS have been reported and whether

you were in contact with someone who had these symptoms.

The Centers for Disease Control has developed infection control recommendations for

patients with suspected SARS in the household.

_ 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, all members of the household with a SARS patient should

carefully follow recommendations for hand hygiene, such as frequent hand washing or

the use of alcohol-based hand rubs.

_ 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 (an N-95 respiratory mask is recommended) during close contact with uninfected

persons. If the patient is unable to wear a respiratory 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. Gloves should be removed and discarded and hands should be washed

immediately after activities involving contact with body fluids. Gloves should not be

washed or reused and are not intended to replace proper hand hygiene.

_ SARS patients should avoid sharing eating and drinking utensils, towels, and bedding

with other members of the household, although these items can be used by others after

routine cleaning, such as washing or laundering with soap and hot water.

_ Common household cleaners are sufficient for disinfecting toilets, sinks, and other

surfaces touched by patients with SARS, but the cleaners must be used frequently.

_ Other members of the household need not restrict their outside activities unless they

develop symptoms of SARS, such as a fever or respiratory illness.

On April 4, 2003, SARS was added to the federal government’s list of quarantinable

communicable diseases by Presidential Executive Order 13295.

Antibody testing can be used to help make a diagnosis, although a positive result may take

up to 3 weeks. Researchers in several countries are working toward developing fast and

accurate laboratory tests for SARS. PCR (polymerase chain reaction) tests appear

promising. However, until those tests have been adequately field tested and shown to be

reliable, SARS diagnosis remains dependant upon the clinical findings of an atypical

pneumonia not attributed to another cause and a history of exposure.

There is currently no treatment known for SARS except for supportive care (treatment

that involves no specific action against the agent causing illness but rather focuses on

maintaining bodily functions). Severe cases will require mechanical ventilation (a

respirator). The recent identification of the virus and the decoding of its genome sequence

will enable scientists to design a therapeutic strategy, including testing specific antiviral

drugs. However, the development of a novel therapy could take years.

Antibiotics have not offered any clinical improvement. In several locations, therapy has

included antiviral drugs such as oseltamivir or ribavirin. Steroids also have been given

orally or intravenously to patients in combination with ribavirin and other antimicrobials.

In the absence of controlled clinical trials, however, the efficacy of these regimens remains

unknown. Early information from laboratory experiments suggests that ribavirin does not

inhibit virus growth or cell-to-cell spread of the new coronavirus that was tested.

Additional laboratory testing of ribavirin and other antiviral drugs is being done to see if

an effective treatment can be found.

There is no vaccine currently available. The recent identification of the virus and the

decoding of its genome sequence will enable scientists to begin developing a vaccine.

However, vaccine development could take years.

Š As with all infectious illnesses, the first line of defense is careful hand hygiene. As a

general rule, it is good practice to wash hands frequently with soap and water; if hands

are not visibly soiled, alcohol-based hand rubs may be used as an alternative.

Š To minimize the possibility of infection, you may wish to avoid close contact with large

numbers of people as much as possible.

Š The Centers for Disease Control does not recommend the routine use of respiratory

masks while in public areas.

Regions most affected by SARS are China; Canada; Hong Kong; Hanoi, Vietnam; and

Singapore. As of April 23, 2003, the World Health Organization (WHO) recommends

that, as a measure of precaution, persons planning to travel to Hong Kong; Guangdong

Province, China; Beijing and Shanxi Province, China; or Toronto, Canada, consider

postponing all but essential travel. Their travel recommendations are continually reviewed

and can be accessed from the WHO link found in the ADDITIONAL RESOURCES

section below. The Centers for Disease Control includes the Peoples Republic of China

(i.e., all of mainland China and Hong Kong), Hanoi, and Singapore in their travel

postponement advisory. Regarding Toronto, the CDC has issued only a "travel alert,"

suggesting that U.S. residents traveling there observe precautions to safeguard their health.

If you decide to go ahead with your travel to an area with SARS, the following guidelines

should be kept in mind:

_ Assemble a travel health kit containing basic first-aid and medical supplies. Include

a thermometer, household disinfectant, a supply of surgical masks and disposable

gloves, and alcohol-based hand rubs for hand hygiene.

_ Inform yourself and others who may be traveling with you about SARS.

_ Be sure you are up to date with all of your shots (vaccinations) and see your

healthcare provider at least 4Š6 weeks before travel to get any additional shots or

information you may need.

_ You may wish to check your health insurance plan or get additional insurance that

covers medical evacuation in the event of illness. Information about medical

evacuation services can be found at this U.S. Department of State page:

_ Identify in-country healthcare resources in advance of your trip.

_ Wash your hands frequently.

_ To minimize the possibility of infection, you may wish to avoid close contact with

large numbers of people as much as possible. The CDC does not recommend the

routine use of masks or other personal protective equipment while in public areas.

_ If you become ill with fever and respiratory symptoms (for example, cough or

shortness of breath), a visit to a doctor is strongly recommended. Tell the doctor

about your symptoms prior to going to the office or emergency room so

arrangements can be made, if necessary, to prevent transmission to others in the

healthcare setting. The nearest U.S. Embassy or Consular Office can help you find

a provider in the area. Again, you are encouraged to identify these resources in

advance. Do not travel while sick and limit your contact with others as much as

possible to help prevent the spread of any infectious illness you may have.

_ The person who is ill should cover their mouth and nose with a facial tissue when

coughing or sneezing. If possible, they should wear a surgical mask (an N-95

respiratory mask is recommended) during close contact with healthy people to

prevent spread of infectious droplets. If the sick person is unable to wear a surgical

mask, other persons should wear surgical masks when in close contact with the

person who is ill.

_ If it is suspected you might have SARS, you would be quarantined.

_ See EMERGENCY RESPONSE, Prevention of SARS transmission in households with

infected persons, section above for guidelines regarding precautionary measures to

take if around potentially infected persons.

_ Persons returning from one of the affected areas should monitor their health for 10

days. Any family member who becomes ill with fever or respiratory symptoms

during this period should consult a doctor and tell him or her about their recent

travel. Tell the doctor about your symptoms prior to going to the office or

emergency room so arrangements can be made, if necessary, to prevent transmission

to others in the healthcare setting.

_ Close contacts of person with SARS who develop fever or respiratory symptoms

should be evaluated by a doctor. Before the evaluation, healthcare providers should

be informed that the individual is a close contact of a person with SARS. These

persons with symptoms of SARS should follow the same precautions recommended

for people with SARS.

A supply of N95 respiratory masks

A supply of disposable gloves

Thermometer

Household disinfectant

Alcohol-based hand rubs for hand hygiene

Isopropyl alcohol (91%)

Sterile gauze pads

Antibacterial soap

Tylenol

Addressing the global threat of SARS: The key to enhancing global response capacity

and reining in this potentially overwhelming outbreak is through a rapid dissemination of

educational materials, both to the lay public and to the multidisciplinary healthcare

workforce.

9-1-1 Center: Resources for responding to terrorism, natural disasters, and household

and other health emergencies

Apple Care Foundation: For information about ongoing research into new treatments,

antidotes, and other medical and public safety programs related to emergent

healthcare issues

Centers for Disease Control (CDC)

Centers for Disease Control: Chemical/Biological/Radiological Hotline for obtaining

information

Hotline: 888-246-2675

National Institutes of Health

State public-health locator for officials, agencies, and public hotlines

World Health Organization (WHO)