Be prepared: SARS and avian flu tracked in Asia

Plans should cover any emerging infections

Confirmed cases of severe acute respiratory syndrome (SARS) in China and the emergence of a new strain of avian flu in Vietnam set the public health world on edge and highlighted one important message for hospitals: Be prepared to encounter newly emerging diseases.

As of late January, there was no person-to-person transmission of SARS, and hospitals remained on the lowest alert status. Yet the Centers for Disease Control and Prevention (CDC) revised its guidance for hospitals to stress some features of the disease that affected the outbreak last year.

If patients are hospitalized with pneumonia or respiratory distress, ask them about travel, the CDC advises. If they’ve been to the Guangdong province of China, they should be placed in isolation and tested for SARS.

If person-to-person transmission occurs anywhere in the world, the level of vigilance rises, says Arjun Srinivasan, MD, medical epidemiologist with the CDC’s Division of Health Care Quality and Promotion and a member of the SARS task force. Anyone with fever or respiratory symptoms should then be asked about travel to areas of known or suspected transmission or contact with possible SARS patients.

Even milder symptoms — chills, myalgia, headache, and diarrhea — can be cause for concern and further evaluation if the person had close contact with a known SARS patient, the CDC says. That would include health care workers who have unprotected exposure to a SARS patient or are involved in a high-risk procedure with a SARS patient.

"We know that there are people who go on to develop SARS who present with some very nonspecific features of the illness," Srinivasan says. "There is a very early stage of the illness, which is characterized by milder symptoms. We think people in this early stage are probably less infectious to other people. But if people have a situation where they have a high-risk exposure, the presence of any of these symptoms should prompt investigation."

Should exposed health care workers continue to work? Should they be furloughed or quarantined? To answer those questions, hospitals should work closely with the public health department, the CDC advises.

"Restrictions on activities on health care workers outside the hospital really need to be coordinated with the health department," points out Srinivasan. "If we did have an outbreak in this country, we would want to make sure if the health department imposed quarantine restrictions, health care workers would have to follow those same restrictions."

Respiratory hygiene works for influenza

Meanwhile, new measures taken to prepare for a recurrence of SARS also could help hospitals avoid nosocomial outbreaks of influenza or protect against pandemic influenza.

Hospitals have begun implementing respiratory hygiene — asking patients with respiratory symptoms to cough into a tissue or to wear a surgical mask. Health care workers examining a patient with respiratory symptoms should use droplet precautions, which includes wearing a surgical mask or procedure mask when in close contact, the CDC says.

"We believe it would work across a range of respiratory pathogens, whether it’s influenza, RSV [respiratory syncytial virus], or tuberculosis," says medical epidemiologist Michele Pearson, MD. "It takes a standard precautions approach to someone who has a potentially infectious respiratory illness."

The respiratory hygiene recommendation is included in influenza materials, upcoming guidelines for isolation precautions, and SARS preparedness, she notes. That underscores the overlap between preparedness efforts for various infectious diseases, Pearson says.

Concerns about pandemic influenza arose in January as 18 people were diagnosed with influenza A (H5N1) after contact with poultry. Six died. A suspected case of human-to-human transmission of H5N1 has been reported by the World Health Organization (WHO) in Geneva.

This strain has "a unique capacity to cause severe disease with high mortality in humans," according to WHO.

"The simultaneous occurrence in several countries of large epidemics of highly pathogenic H5N1 influenza in domestic poultry is historically unprecedented," the agency reported.

"The present situation may grow worse. In bird populations, the disease is highly contagious and rapidly fatal and spreads easily from farm to farm." Millions of poultry were being killed to prevent spread of the disease in Asia.

Hospitals should review their preparedness plans to make sure they have information on pandemic influenza, yet they do not need a special plan for the disease, Pearson says.

"There needs to be a core plan of preparedness and not a disease du jour preparedness," she says. "Whether you’re talking about bioterrorism, influenza, or SARS, you have the same considerations in terms of staffing, surge capacity, and other issues."

For example, hospitals should have strategies for getting additional staffing or equipment in the event of a community outbreak — regardless of the agent. "You don’t know the hour and day and time that it’s going to happen," Pearson says. "If you wait until it’s at your doorstep, then you’re not likely to be ready to deal with it."

(Editor’s note: The updated Public Health Guidance for Community-Level Preparedness and Response to SARS is available at www.cdc.gov/ncidod/sars/guidance/index.htm. For more information on hospital infection control and influenza, go to: www.cdc.gov/flu/professionals/infectioncontrol/index.htm.)