Severe Acute Respiratory Syndrome
Health Advisory - January 14, 2004
Health Advisory: SARS in China; Influenza H5N1 (Avian Flu in Vietnam, Korea and Japan)
CDC today is advising clinicians to have a high index of suspicion for SARS when evaluating persons hospitalized with radiographically confirmed pneumonia or acute respiratory distress syndrome (ARDS) AND who have a history of travel to Guangdong Province (or close contact with an ill person with a history of recent travel to Guangdong Province) in the 10 days before onset of symptoms.
Such cases should be reported promptly and SARS ISOLATION PRECAUTIONS (contact and airborne) should be used - see details below.
In addition, an outbreak of avian influenza with a high mortality rate is occurring in Vietnam. Healthcare providers should identify and report patients hospitalized with unexplained pneumonia, ARDS, or severe respiratory illness AND who have traveled to Vietnam, South Korea, and Japan within 10 days from onset of symptoms. All such patients should be tested for influenza virus infection, including viral culture of nasopharyngeal and throat swabs.
The full CDC advisory follows: CDC Health Advisory Distributed via Health Alert Network
Third Possible SARS Case Reported in China; Influenza A (H5N1) Infections Reported in Vietnam
This advisory provides updated information and recommendations following recent reports of cases of severe acute respiratory syndrome (SARS) in Guangdong Province, China, and human cases of influenza A (H5N1) virus infections in Vietnam. No travel alerts or advisories to these regions have been issued by the Centers for Disease Control and Prevention (CDC), but increased vigilance is advised for ill persons traveling to the United States from Guangdong Province and Vietnam, Japan, and South Korea.
Severe Acute Respiratory Syndrome
Recent SARS Cases in China
On January 13, 2004, the Chinese Ministry of Health (MOH) and the World Health Organization (WHO) reported a new suspect case SARS in a 35-year-old man living in Guangdong Province, China. This case is the third recent report of suspected or confirmed SARS in patients in southern China. No link has been established at present between the confirmed case and the two recent suspect SARS cases, and the source of exposure for all three cases is unclear.
On January 5, 2004, Chinese and WHO authorities announced that laboratory results confirmed evidence of SARS-associated coronavirus infection (SARS-CoV) in a 32-year-old man in Guangdong Province who had become ill on December 16, 2003. On January 8, 2004, a suspect case of SARS was reported in a 20-year-old woman who works in a restaurant in Guangdong Province and had onset of illness on December 25, 2003. On January 12, 2004, a suspect case of SARS was reported in a 35-year-old man from Guangdong Province who had onset of illness on December 31, 2003, and was admitted to Guangdong People's Hospital and placed in isolation on January 6. All three patients are reported to be doing well, and no signs or symptoms of SARS-like illness have been reported among their identified contacts to date. Details on the clinical features and laboratory results of the 2 suspect SARS cases are not yet available.
Recommended U.S. SARS Control Measures
In light of these reports, the CDC is recommending that U.S. physicians maintain a greater index of suspicion of SARS in patients who require hospitalization for radiographically confirmed pneumonia or acute respiratory distress syndrome (ARDS) AND who have a history of travel to Guangdong Province (or close contact with an ill person with a history of recent travel to Guangdong Province) in the 10 days before onset of symptoms. When such patients are identified, the following actions should be taken:
Advice for Travelers (SARS)
At this time, WHO and CDC have not issued any alerts or advisories for travel to China (www.cdc.gov/ncidod/sars/travel_alertadvisory.htm). Previous SARS research has shown that SARS can be controlled and contained through early detection, isolation of suspect cases, and tracing of their contacts.
On the basis of limited available data, it would be prudent for travelers to China to avoid visiting live food markets and avoid direct contact with civets and other wildlife from these markets. Although there is no evidence that direct contact with civets or other wild animals from live food markets has led to cases of SARS, viruses very similar to SARS-CoV-the virus that causes SARS-have been found in these animals. In addition, some persons working with these animals have evidence of infection with SARS-CoV or a very similar virus.
US Bans Importation of Civet Cats
On January 13, 2004, the Department of Health and Human Services (HHS) announced an immediate embargo on the importation of civets to the United States (www.cdc.gov/ncidod/sars/civet_ban_exec_order.htm). These small animals have been identified as a possible link to SARS transmission in China. The embargo, which applies to dead and live civets as well as civet products, will remain in place until further notice. Civet products that have been processed to render them noninfectious, such as fully taxidermied animals and finished trophies, are not included in the embargo. The ban does not apply to civet cats approved by CDC for importation for educational or scientific purposes.
More Information About SARS
For more information about current U.S. SARS control guidelines, see the CDC document, "In the Absence of SARS-CoV Transmission Worldwide: Guidance for Surveillance, Clinical and Laboratory Evaluation, and Reporting" at www.cdc.gov/ncidod/sars/absenceofsars.htm. The document is part of CDC's draft Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) www.cdc.gov/ncidod/sars/sarsprepplan.htm.
For additional information about the reported SARS cases in China, see the Web sites of CDC (www.cdc.gov) and WHO (www.who.int/en).
Influenza A (H5N1) Virus Infections: Recent Influenza A (H5N1) Cases
Since the end of October 2003, 14 persons (13 children and 1 adult) in Vietnam have been admitted from surrounding provinces to hospitals in Hanoi for severe respiratory illness. Among the 14 patients, three (2 children and 1 adult) have had avian influenza A (H5N1) virus infections confirmed by testing conducted at the National Institute of Hygiene and Epidemiology in Hanoi and in Hong Kong. Twelve of the patients, including 11 children and the mother of one of the deceased children, have died.
Influenza A (H5N1) viruses normally circulate among wild birds but can infect poultry and rarely have infected people in the past. In 1997, 18 persons in Hong Kong were hospitalized because of influenza A (H5N1) infections and six of them died. In 2003, two residents of Hong Kong who traveled to China developed influenza A (H5N1) virus infections and one of them died. In Vietnam, large outbreaks of influenza A (H5N1) have been reported among poultry in the southern and northern regions of the country. WHO has reported that the H5N1 strain implicated in the outbreak has now been partially sequenced. All genes are of avian origin, indicating that the virus that caused death in the three confirmed cases had not yet acquired human genes. The acquisition of human genes increases the likelihood that a virus of avian origin can be readily transmitted from one human to another.
Staff from CDC will travel to Vietnam to work with WHO and Vietnam's human and animal health authorities to evaluate the situation, including patterns of transmission of the influenza A (H5N1) viruses.
During December 2003, an outbreak of avian influenza A (H5N1) was reported among poultry in South Korea. Earlier this week, Japan reported the deaths of 6,000 chickens on a single farm in the western part of Honshu due to influenza A (H5N1) virus infection. No human cases of infection with the avian influenza virus have been reported in either of these outbreaks.
Enhanced U.S. Influenza Surveillance
At this time, CDC recommends enhanced surveillance efforts by state and local health departments, hospitals, and clinicians to identify patients who have been hospitalized with unexplained pneumonia, ARDS, or severe respiratory illness AND who have traveled to Vietnam, South Korea, and Japan within 10 days from onset of symptoms.
All such patients should be tested for influenza virus infection; these tests should include viral culture of nasopharyngeal and throat swabs. All influenza A viruses should be subtyped, and those that cannot be identified as H3 or H1 viruses should be sent immediately to CDC for testing for influenza A (H5N1). CDC will make additional recommendations on enhanced surveillance if influenza A (H5N1) activity continues to evolve.
SARS and Influenza A (H5N1)
There is considerable potential for the clinical presentation and travel history of persons with either SARS or influenza A (H5N1) infection to overlap. Therefore, the following actions should be taken:
