SARS Advisory for Clinicians: February 3, 2004

Severe Acute Respiratory Syndrome
Health Advisory - February 3, 2004

Health Advisory: Update on Influenza A (H5N1) and SARS: Interim Recommendations for Enhanced U.S. Surveillance, Testing, and Infection Control

CDC today issued new guidance related to avian influenza A (H5N1) and SARS. The CDC advisory contains important NEW information about diagnosis, infection control precautions for influenza H5N1. There are no new changes in SARS recommendations. King County health care providers are requested to review the CDC advisory, reproduced below.

Summary of Key Points:

Influenza A (H5N1)

	Infections of H5N1 among poultry have been confirmed in Cambodia, China, Hong Kong SAR, Indonesia, Japan, Korea, Laos, Thailand, and Vietnam. A cluster of four cases of severe respiratory illness in a single family is under investigation; limited human-to-human transmission may be one possible explanation, but direct poultry-to-human transmission cannot be ruled out, according to the World Health Organization (WHO). At this time, there is no evidence of efficient person-to-person transmission in Vietnam or elsewhere.
	Testing for influenza A (H5N1) is indicated for hospitalized patients with:
	a.	radiographically confirmed pneumonia, acute respiratory distress syndrome (ARDS), or other severe respiratory illness for which an alternate diagnosis has not been established, AND
	b.	history of travel within 10 days of symptom onset to a country with documented H5N1 avian influenza in poultry and/or humans (for a listing of H5N1-affected countries, see the OIE Web site at www.oie.int/eng/en_index.htm and the WHO Web site at www.who.int/en/).
	Report suspected cases of influenza H5N1 immediately to Public Health at 206-296-4774
	Testing for influenza A (H5N1) should be considered on a case-by-case basis in consultation with Public Health (206-296-4774) for hospitalized or ambulatory patients with:
	a.	documented temperature of >38°C (>100.4°F), AND
	b.	one or more of the following: cough, sore throat, shortness of breath, AND
	c.	history of contact with domestic poultry (e.g., visited a poultry farm, household raising poultry, or bird market) or a known or suspected human case of influenza A (H5N1) in an H5N1-affected country within 10 days of symptom onset.
	Isolation precautions identical to those recommended for SARS should be implemented for all hospitalized patients diagnosed with or under evaluation for influenza A (H5N1).
	CDC does not recommend that virus isolation studies on respiratory specimens from patients who meet the above criteria be conducted unless stringent BSL 3+ conditions can be met. Therefore, respiratory virus cultures should not be performed in most clinical laboratories and such cultures should not be ordered for patients suspected of having H5N1 infection.
	Clinical specimens from suspect A (H5N1) cases and SARS-CoV cases may be tested by PCR assays using standard BSL 2 work practices in a Class II biological safety cabinet. In addition, commercial antigen detection testing can be conducted under BSL 2 levels to test for influenza.

SARS

	Since December 16th, 2003, 4 SARS cases (three confirmed, one probable) have been reported in China. All four patients have recovered from their illness and have been discharged from the hospital. To date, none of the contacts of these cases has developed a SARS-like illness. The source of infection in these individuals has not been determined.
	CDC continues to recommend consideration of testing for SARS-CoV in patients who require hospitalization for radiographically confirmed pneumonia or ARDS without identifiable etiology AND who have one of the following risk factors in the 10 days before the onset of illness:
		Travel to mainland China, Hong Kong, or Taiwan, or close contact with an ill person with a history of recent travel to one of these areas, OR
		Employment in an occupation associated with a risk for SARS-CoV exposure (e.g., health care worker with direct patient contact; worker in a laboratory that contains live SARS-CoV), OR
		Part of a cluster of cases of atypical pneumonia without an alternative diagnosis.
	For patients with pneumonia or ARDS who have recently traveled to Guangdong Province, China, diagnostic testing for SARS-CoV should be performed immediately. For other patients, diagnostic testing for SARS should proceed for such patients as described in guidelines at www.cdc.gov/ncidod/sars/absenceofsars.htm.