Severe Acute Respiratory Syndrome
Established Infectious Disease Control Measures Helped Contain Spread, But a Large-Scale Resurgence May Pose Challenges Gao ID: GAO-03-1058T July 30, 2003SARS is a highly contagious respiratory disease that infected more than 8,000 individuals in 29 countries principally throughout Asia, Europe, and North America and led to more than 800 deaths as of July 11, 2003. Due to the speed and volume of international travel and trade, emerging infectious diseases such as SARS are difficult to contain within geographic borders, placing numerous countries and regions at risk with a single outbreak. While SARS did not infect large numbers of individuals in the United States, the possibility that it may reemerge raises concerns about the ability of public health officials and health care workers to prevent the spread of the disease in the United States. GAO was asked to assist the Subcommittee in identifying ways in which the United States can prepare for the possibility of another SARS outbreak. Specifically, GAO was asked to determine 1) infectious disease control measures practiced within health care and community settings that helped contain the spread of SARS and 2) the initiatives and challenges in preparing for a possible SARS resurgence.
Infectious disease experts emphasized that no new infectious disease control measures were introduced to contain SARS in the United States. Instead, strict compliance with and additional vigilance to enforce the use of current measures was sufficient. These measures--case identification and contact tracing, transmission control, and exposure management--are well established infectious disease control measures that proved effective in both health care and community settings. The combinations of measures that were used depended on either the prevalence of the disease in the community or the number of SARS patients served in a health care facility. For SARS, case identification within health care settings included screening individuals for fever, cough, and recent travel to a country with active cases of SARS. Contact tracing, the identification and tracking of individuals who had close contact with someone who was infected or suspected of being infected, was important for the identification and tracking of individuals at risk for SARS. Transmission control measures for SARS included contact precautions, especially hand washing after contact with someone who was ill, and protection against respiratory spread, including spread by large droplets and by smaller airborne particles. The use of isolation rooms with controlled airflow and the use of respiratory masks by health care workers were key elements of this approach. Exposure management practices--isolation and quarantine--occurred in both health care and home settings. Effective communication among health care professionals and the general public reinforced the need to adhere to infectious disease control measures. While no one knows whether there will be a resurgence of SARS, federal, state, and local health care officials agree that it is necessary to prepare for the possibility. As part of these preparations, CDC, along with national associations representing state and local health officials, and others, is involved in developing both SARS-specific guidelines for using infectious disease control measures and contingency response plans. In addition, these associations have collaborated with CDC to develop a checklist of preparedness activities for state and local health officials. Such preparation efforts also improve the health care system's capacity to respond to other infectious disease outbreaks, including those precipitated by bioterrorism. However, implementing these plans during a large-scale outbreak may prove difficult due to limitations in both hospital and workforce capacity that could result in overcrowding, as well as potential shortages in health care workers and medical equipment--particularly respirators.
GAO-03-1058T, Severe Acute Respiratory Syndrome: Established Infectious Disease Control Measures Helped Contain Spread, But a Large-Scale Resurgence May Pose Challenges
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Testimony:
Before the Permanent Subcommittee on Investigations, Committee on
Governmental Affairs, U.S. Senate:
United States General Accounting Office:
GAO:
For Release on Delivery Expected at 9:00 a.m.
Wednesday, July 30, 2003:
SEVERE ACUTE RESPIRATORY SYNDROME:
Established Infectious Disease Control Measures Helped Contain Spread,
But a Large-Scale Resurgence May Pose Challenges:
Statement of Marjorie E. Kanof:
Director, Health Care--Clinical and Military Health Care Issues:
GAO-03-1058T:
GAO Highlights:
Highlights of GAO-03-1058T, a report to the Permanent Subcommittee on
Investigations, Committee on Governmental Affairs, U.S. Senate
Why GAO Did This Study:
SARS is a highly contagious respiratory disease that infected more
than 8,000 individuals in 29 countries principally throughout Asia,
Europe, and North America and led to more than 800 deaths as of July
11, 2003. Due to the speed and volume of international travel and
trade, emerging infectious diseases such as SARS are difficult to
contain within geographic borders, placing numerous countries and
regions at risk with a single outbreak. While SARS did not infect
large numbers of individuals in the United States, the possibility
that it may reemerge raises concerns about the ability of public
health officials and health care workers to prevent the spread of the
disease in the United States.
GAO was asked to assist the Subcommittee in identifying ways in which
the United States can prepare for the possibility of another SARS
outbreak. Specifically, GAO was asked to determine 1) infectious
disease control measures practiced within health care and community
settings that helped contain the spread of SARS and 2) the initiatives
and challenges in preparing for a possible SARS resurgence.
What GAO Found:
Infectious disease experts emphasized that no new infectious disease
control measures were introduced to contain SARS in the United States.
Instead, strict compliance with and additional vigilance to enforce
the use of current measures was sufficient. These measures”case
identification and contact tracing, transmission control, and exposure
management”are well-established infectious disease control measures
that proved effective in both health care and community settings. The
combinations of measures that were used depended on either the
prevalence of the disease in the community or the number of SARS
patients served in a health care facility. For SARS, case
identification within health care settings included screening
individuals for fever, cough, and recent travel to a country with
active cases of SARS. Contact tracing, the identification and tracking
of individuals who had close contact with someone who was infected or
suspected of being infected, was important for the identification and
tracking of individuals at risk for SARS. Transmission control
measures for SARS included contact precautions, especially hand
washing after contact with someone who was ill, and protection against
respiratory spread, including spread by large droplets and by smaller
airborne particles. The use of isolation rooms with controlled airflow
and the use of respiratory masks by health care workers were key
elements of this approach. Exposure management practices”isolation and
quarantine”occurred in both health care and home settings. Effective
communication among health care professionals and the general public
reinforced the need to adhere to infectious disease control measures.
While no one knows whether there will be a resurgence of SARS,
federal, state, and local health care officials agree that it is
necessary to prepare for the possibility. As part of these
preparations, CDC, along with national associations representing state
and local health officials, and others, is involved in developing both
SARS-specific guidelines for using infectious disease control measures
and contingency response plans. In addition, these associations have
collaborated with CDC to develop a checklist of preparedness
activities for state and local health officials. Such preparation
efforts also improve the health care system‘s capacity to respond to
other infectious disease outbreaks, including those precipitated by
bioterrorism. However, implementing these plans during a large-scale
outbreak may prove difficult due to limitations in both hospital and
workforce capacity that could result in overcrowding, as well as
potential shortages in health care workers and medical equipment”
particularly respirators.
www.gao.gov/cgi-bin/getrpt?GAO-03-1058T.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Marjorie E. Kanof at
(202) 512-7101.
[End of section]
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today as you consider effective infectious
disease control measures to help contain the spread of Severe Acute
Respiratory Syndrome (SARS) should future outbreaks occur. SARS is a
highly contagious respiratory disease that infected more than 8,000
individuals in 29 countries principally throughout Asia, Europe, and
North America and led to more than 800 deaths as of July 11, 2003. Due
to the speed and volume of international travel and trade, emerging
infectious diseases such as SARS are difficult to contain within
geographic borders, placing numerous countries and regions at risk with
a single outbreak. SARS quickly became a worldwide health problem,
prompting the World Health Organization (WHO) to issue a global alert
for the first time in more than a decade--an alert that was cancelled
on July 5, 2003. Although the outbreak is currently believed to be
contained, the fact that SARS is a type of coronavirus--the source of
some common colds--leads many to suggest that SARS could be seasonal
and as such could recur in the fall and winter months.
Although all the modes of SARS transmission may not have been
identified, the disease is most likely spread through person-to-person
contact. Experts agree that infected individuals are contagious when
symptomatic--a time during which they are more likely to seek medical
attention and come into contact with health care workers. One unique
characteristic of the SARS outbreak was the high rate of infection
among health care workers, who--before the institution of specific
protective measures--may have become infected while treating patients
with SARS. The SARS outbreak in Asia demonstrated that the disease can
also spread rapidly in the community, outside of hospital settings.
While SARS did not infect large numbers of individuals in the United
States, the possibility that it may reemerge raises concerns about the
ability of public health officials and health care workers to prevent
the spread of the disease in the United States. To assist the
Subcommittee in identifying ways in which the United States can prepare
for the possibility of another SARS outbreak, my remarks today will
focus on 1) infectious disease control measures practiced within health
care and community settings that helped contain the spread of SARS and
2) the initiatives and challenges in preparing for a possible SARS
resurgence.
My testimony today is based on the review of documentation about
infection control practices and guidelines, as well as descriptions
about the origin of SARS and its spread. In addition, we spoke with
leading national and international disease experts--most of whom were
involved in either the investigation of SARS or in the treatment of
patients with SARS. Specifically, we spoke with experts in infectious
diseases, epidemiology, clinical medicine, and occupational safety from
the Centers for Disease Control and Prevention (CDC) and WHO. We also
spoke with public health officials of Health Canada and Toronto Public
Health because Canada had the highest prevalence of SARS cases in North
America. We interviewed state and local public health officials in
California and New York--both of which had the greatest number of SARS
cases reported in the United States. These officials represented the
California Department of Health Services, the New York State Department
of Health, and the New York City Department of Health and Mental
Hygiene. We also spoke with hospital infectious disease experts in each
of these states. In addition, we spoke with national infectious disease
experts, hospital epidemiologists, and representatives from the
National Association of County and City Health Officials (NACCHO) and
the Association of State and Territorial Health Officials (ASTHO). We
also used our previous work on the capacity of the public health system
to respond to both bioterrorism and emerging infectious
diseases.[Footnote 1] We conducted our work in July 2003 in accordance
with generally accepted government auditing standards.
In summary, infectious disease experts emphasized that no new
infectious disease control measures were introduced to contain SARS in
the United States. Instead, strict compliance with and additional
vigilance to enforce the use of current measures was sufficient. These
measures--case identification and contact tracing, transmission
control, and exposure management--are well-established infectious
disease control measures that proved effective in both health care and
community settings. The combinations of measures that were used
depended on either the prevalence of the disease in the community or
the number of SARS patients served in a health care facility. For SARS,
case identification within health care settings included screening
individuals for fever, cough, and recent travel to a country with
active cases of SARS. Contact tracing, the identification and tracking
of individuals who had close contact with someone who was infected or
suspected of being infected, was important for the identification and
tracking of individuals at risk for SARS. Transmission control measures
for SARS included contact precautions, especially hand washing after
contact with someone who was ill, and protection against respiratory
spread, including spread by large droplets and by smaller airborne
particles. The use of isolation rooms with controlled airflow and the
use of respiratory masks by health care workers were key elements of
this approach. Exposure management practices--isolation and
quarantine--occurred in both health care and home settings. Effective
communication among health care professionals and the general public
reinforced the need to adhere to infectious disease control measures.
While no one knows whether there will be a resurgence of SARS, federal,
state, and local health care officials we interviewed agree that it is
necessary to prepare for the possibility. As part of these
preparations, CDC, along with national associations that represent
state and local health officials, and others, is involved in developing
both SARS-specific guidelines for using infectious disease control
measures and contingency response plans. In addition, these
associations have collaborated with CDC to develop a checklist of
preparedness activities for state and local health officials. Such
preparation efforts also improve the health care system's capacity to
respond to other infectious disease outbreaks, including those
precipitated by bioterrorism. However, implementing these plans may
prove difficult due to limitations in both hospital and workforce
capacity. A large-scale SARS outbreak could create overcrowding, as
well as shortages in health care workers and in medical equipment--
particularly respirators.
Background:
SARS is an emerging respiratory disease that has been reported
principally in Asia, Europe, and North America. SARS is believed to
have originated in Guangdong Province, China in mid-November 2002.
However, early cases of the disease went unreported, which then delayed
identification and treatment of the disease allowing it to spread. On
February 11, 2003, WHO received its first official report of an
atypical pneumonia outbreak in China. This report stated that 305
individuals were affected by atypical pneumonia and that 5 deaths had
been attributed to the disease. SARS was transmitted out of the
Guangdong Province on February 21, 2003, by a physician who became
infected after treating patients in the province. Subsequently, the
physician traveled to a hotel in Hong Kong and began suffering from
flu-like symptoms. Days later, other guests and visitors at the hotel
contracted SARS. As infected hotel patrons traveled to other countries,
such as Vietnam and Singapore, and sought medical attention for their
symptoms, they spread the disease throughout each country's hospitals
as well as in some communities. Simultaneously, the disease began
spreading around the world along international air travel routes as
guests from the hotel flew homeward to Toronto and elsewhere.
Description of Severe Acute Respiratory Syndrome:
Scientific evidence indicates that SARS is caused by a previously
unrecognized coronavirus.[Footnote 2] Transmission of SARS appears to
result primarily from close person-to-person contact[Footnote 3] and
contact with large respiratory droplets emitted by an infected person
who coughs or sneezes. After contact, the incubation period for SARS--
the time it takes for symptoms to appear after an individual is
infected--is generally within a 10-day period. Clinical evidence to
date also suggests that people are most likely to be contagious at the
height of their symptoms. However, it is not known how long after
symptoms begin that patients with SARS are capable of transmitting the
virus to others. There is no evidence that SARS can be transmitted from
asymptomatic individuals.
Currently, there is no definitive test to identify SARS during the
early phase of the illness, which complicates diagnosing infected
individuals. As a result, the early diagnosis of SARS relies more on
interpreting individuals' symptoms and identification of travel to
locations with SARS transmission. SARS symptoms include fever, chills,
headaches, body aches, and respiratory symptoms such as shortness of
breath and dry cough--making SARS difficult to distinguish from other
respiratory illnesses, such as the flu and pneumonia. The initial
symptoms can be quite mild, and gradually increase in severity, often
peaking in the second week of illness. In some individuals, the disease
might progress to the point where insufficient oxygen is getting to the
blood.
CDC has established for health care providers criteria used for the
identification of individuals with SARS, called case
definitions.[Footnote 4] In the absence of a definitive diagnostic test
for the disease in its early phase, reported cases of SARS are
classified into two categories based on clinical and epidemiologic
criteria--"suspect" and "probable." These case definitions continue to
be refined as more is learned about this disease. A "suspect" case of
SARS includes the following criteria:
* high fever,
* respiratory illness, and:
* recent travel to an area with current or previously documented
suspected transmission of SARS,[Footnote 5] and/or:
* close contact within 10 days of the onset of symptoms with a person
known or suspected to have SARS.
A "probable" case of SARS includes the following criteria:
* all the criteria for "suspect" cases and:
* evidence in the form of chest x-ray findings of pneumonia, acute
respiratory distress syndrome (ARDS), or an unexplained respiratory
illness resulting in death with autopsy findings of ARDS.
The final determination of whether cases meeting the definitions for
"suspect" and "probable" SARS are due to infection with the SARS virus
is based on results of testing a blood specimen obtained 28 days after
the onset of illness.
Furthermore, there is no specific treatment for SARS. In the absence of
a rapid diagnostic test, it can be very difficult to distinguish
clinically between individuals with SARS and individuals with atypical
pneumonia. Therefore, CDC currently recommends that individuals
suspected of having SARS be managed using the same diagnostic and
therapeutic strategies that would be used for any patient with serious
atypical pneumonia. In mild cases of SARS, management at home may be
appropriate, while more severe cases may require treatment, such as
intravenous medication and oxygen supplementation, that necessitates
hospitalization. In 10 to 20 percent of SARS cases, patients require
mechanical ventilation.[Footnote 6] As of July 11, 2003, the mortality
rate for SARS was approximately 10 percent, but the mortality rates in
individuals over 60 years of age approached 50 percent.
As of July 11, 2003, WHO reported that there were an estimated 8,427
"probable" cases from 29 countries, with 813 deaths from SARS. China,
Hong Kong, Singapore, Taiwan, and Canada reported the highest number of
cases. As of July 15, 2003, the United States identified 211 SARS cases
in 39 states (including Puerto Rico), with no related deaths. Of these
cases, 175 are classified as "suspect" cases, while 36 are classified
as "probable."[Footnote 7] In the United States, 34 of the 36
"probable" cases contracted SARS through international travel. However,
in the other affected countries, SARS spread extensively among health
care workers. For example, of the 138 diagnosed cases in Hong Kong as
of March 25, 2003, that were not due to travel, 85 (62 percent)
occurred among health care workers; among the 144 cases in Canada as of
April 10, 2003, 73 (51 percent) were health care workers.
General Infectious Disease Control Measures:
In the United States, the Healthcare Infection Control Practices
Advisory Committee (HICPAC), a federal advisory committee made up of 14
infection control experts, develops recommendations and guidelines
regarding general infectious disease control measures for CDC.
Important components of these infectious disease control measures are
the following: case identification and contact tracing, transmission
control, and exposure management.
Case Identification and Contact Tracing. Case identification and
contact tracing are considered by health care providers to be important
first steps in the containment of infectious diseases in both the
community and health care settings. Case identification is the process
of determining whether or not a person meets the specific definitions
for a given disease. Generally, health care providers interview
patients in order to obtain the history, signs, and symptoms of the
patient's complaint and perform a physical examination. Tests, such as
blood tests or x-rays, can be performed to provide additional
information to help determine the diagnosis. Public awareness of the
symptoms of a disease can help case identification to the extent that
individuals who believe they exhibit the symptoms seek medical
attention. Contact tracing involves the identification and tracking of
individuals who may have been exposed to a person with a specific
disease.
Transmission Control. Transmission control measures decrease the risk
for transmission of microorganisms through proper hand hygiene and the
use of personal protective equipment, such as masks, gowns, and gloves.
These measures also include the decontamination of objects and rooms.
The types of transmission control measures used are based on how an
illness is transmitted. For example, some categories of transmission
are as follows:
* Direct contact: person-to-person contact (e.g., two people shaking
hands) and physical transfer of the microorganism between an infected
person and an uninfected person.
* Indirect contact: contact with a contaminated object, such as
secretions from an infected person on a doorknob or telephone receiver.
* Droplet: eye, nose, or mouth of an uninfected person coming into
contact with droplets (larger than 5 micrometers) containing the
microorganism from an infected person, for example an infected person
sneezing without covering his/her mouth with a tissue.
* Airborne: contact with small droplets (5 micrometers or smaller) or
dust particles containing the microorganism, which are suspended in the
air.
Exposure Management. Exposure management is the separation of infected
individuals from noninfected individuals through isolation or
quarantine. Isolation refers to the separation of individuals who have
a specific infectious illness from healthy individuals and the
restriction of their movement to contain the spread of that illness.
Quarantine refers to the separation and restriction of movement of
individuals who are not yet ill, but who have been exposed to an
infectious agent and are potentially infectious.
The success of these infectious disease control measures--case
identification and contact tracing, transmission control, and exposure
management--depends, in part, on the frequent and timely exchange of
information. Public health officials and health care providers need to
be informed about any modifications of existing infectious disease
control measures, the geographic progression of an outbreak, and
reports of disease occurrence. Likewise, elevating public knowledge
about an infectious disease and its symptoms will enable infected
individuals to seek medical attention as soon as possible to contain
the spread.
Experts Recommend Case Identification and Contact Tracing, Transmission
Control, and Exposure Management Measures To Prevent the Spread of
SARS:
Infectious disease experts emphasized that existing infectious disease
control measures played a pivotal role in containing the spread of SARS
in both health care and community settings. The combinations of
measures that were used depended on either the prevalence of the
disease in the community or the number of SARS patients served in a
health care facility. No new measures were introduced to contain the
SARS outbreak in the United States; instead, experts said strict
compliance with and additional vigilance to enforce the use of current
measures was sufficient. The successful implementation of all of the
infectious disease control measures depended, in part, on effective
communication among health care professionals and the general public.
Timely Case Identification and Contact Tracing of SARS Cases Was
Critical But Difficult:
To prevent the spread of SARS, public health authorities worked to
identify every individual who might have been infected with the
disease. Rapid identification of these individuals was critical, but
the lack of an effective and timely diagnostic test that could be used
during the early stages of the disease to identify those who actually
had SARS was an obstacle in halting its spread. Experts acknowledged
that identification of individuals who might have been infected with
the SARS virus was likely to include many people who did not have SARS
because the case definition of an individual with SARS is not highly
specific and the disease resembles other respiratory illnesses, such as
pneumonia and the flu. The long incubation period for SARS provided
health care workers the opportunity to identify cases and close
contacts of infected individuals before those who actually had the SARS
virus could spread the disease to others.
An important part of case identification is screening individuals for
symptoms of a disease. CDC recommended that when individuals called for
appointments and as soon as possible after the individual arrived in a
health care setting, all individuals should be screened with targeted
questions concerning SARS-related symptoms, close contact with a SARS
suspect case patient, and recent travel. For SARS, public health and
hospital officials in California and New York said hospital emergency
room or other waiting room staff routinely used questionnaires to
screen incoming patients for fever, cough, and travel to a country with
active cases of SARS. They said that hospitals' signs in various
locations generally used by incoming patients and visitors also
included these criteria and asked individuals to identify themselves to
hospital staff if they met them. According to these officials, an
individual identified as a potential SARS case generally was given a
surgical mask and moved into a separate area for further medical
evaluation. CDC officials said that these measures were also important
for physicians in private practice. The New York City and California
health departments used e-mail health alert notices to inform private
physicians, such as family practitioners and pediatricians, about these
case identification procedures. These notices directed physicians to
information posted on the health departments' Web sites. In addition,
officials from these health departments provided information about SARS
case identification, among other topics, during local meetings for
members of the medical community, including physicians in private
practice.
Toronto, which experienced a much greater prevalence of SARS than the
United States, used somewhat different case identification practices.
At the height of the outbreak in Toronto, everyone entering a hospital
was required to answer screening questions and to have their
temperature checked before they were allowed to enter. Toronto public
health department officials said this heightened screening was useful
for case identification and had an added benefit of educating staff and
visitors about SARS symptoms. As a further measure, Toronto health
officials established SARS assessment clinics, also known as fever
clinics; persons suspecting they might have SARS were asked to go to
the clinics rather than directly to hospital emergency rooms to avoid
infecting other individuals. However, officials acknowledged several
limitations to using these assessment clinics. Because there was no
follow-up to an initial assessment, some SARS cases that were in the
early stages were not identified, but later these individuals went to
hospital emergency rooms. Other difficulties included finding
physicians to staff the clinics and implementing hospital-level
infectious disease control measures at these separate clinics. For
example, some clinics were set up in non-hospital locations--one
assessment clinic was set up in a tent near a hospital emergency room
entrance, while another was situated in a hospital ambulance bay where
emergency personnel transfer patients into the hospital.
Contact tracing--the identification and tracking of individuals who had
close contact with a "suspect" or "probable" case--is an important
component of case identification. Contact tracing to identify
individuals at significant risk for SARS required significant local
health department resources. In New York City, four teams from the
communicable disease bureau, comprised of either a physician or nurse
and several field workers, interviewed each suspect or probable case in
order to identify contacts. They then called each contact to advise
them of their exposure and provided information on monitoring for
symptoms of SARS and receiving treatment if necessary. The calls were
also to ensure that the contacts were following infection control
measures in the home. Each contact received routine calls during a 10-
day period--an average of four calls each from a team member. A New
York City health department official characterized the process of
contact tracing as labor and time intensive. Standardized forms and
electronic contact and case databases helped the teams manage contact
tracing. Additionally, routine weekly meetings with other health
department divisions ensured that if assistance was needed from these
departments, they would be up-to-date. Furthermore, New York City
developed procedure manuals that would allow staff from other
departments to be trained quickly if needed to assist members of the
communicable disease bureau. The health department official emphasized
that the electronic database created to log information about SARS
contacts was an important tool to facilitate contact tracing. Toronto
officials agreed that daily contact tracing required a large amount of
resources. Adding to Toronto's difficulties, its health department did
not have an electronic case or contact database, but had to rely on
separate paper files for each individual.
Multiple Transmission Control Measures Used to Contain Spread:
Experts recommended a combination of transmission control measures
because not all modes of SARS transmission are known. The primary mode
of transmission is direct person-to-person contact, although contact
with body fluids and contaminated objects, and possibly airborne
spread, may play a role. Therefore, multiple infection control
practices that are used for each type of transmission are included in
SARS infection control guidelines. Some combination of practices was
recommended for both health care settings and in the community, with
more intensive infection control procedures recommended for health care
settings. According to several experts, the simple "things your mother
taught you," such as washing your hands and covering your mouth and
nose with a tissue when sneezing or coughing were effective in reducing
the spread of SARS.
CDC prepared SARS guidelines for transmission control measures for both
inpatient (such as hospitals) and outpatient (such as physician
offices) health care settings.[Footnote 8] These recommendations
combined what the CDC calls "standard" hospital transmission control
measures with transmission control measures specific to contact and
airborne transmission. For the inpatient setting, the guidelines
included:
* Routine standard precautions, including hand washing. In addition to
standard precautions, CDC recommended eye protection--such as goggles
or a face shield.
* Contact precautions, such as the use of a gown and gloves for
encounters with the patient or his/her environment.
* Airborne precautions, such as an isolation room with negative
pressure relative to the surrounding area,[Footnote 9] and the use of
an N-95 filtering disposable respirator for persons entering the room.
The CDC guidelines suggested that if an isolation room was not
available, patients should be placed in a private room, and all persons
entering the room should wear N-95 respirators (or respirators offering
comparable protection) to protect the wearer from particles expelled by
a sick person, such as in coughing or sneezing. CDC recommended that,
where possible, a test to ensure that the N-95 respirators fit properly
should be conducted. If N-95 respirators were not available for health
care personnel, then surgical masks should be worn. Generally, the
material of N-95 respirators is designed to filter smaller particles
than a surgical mask, and they also are designed to seal more tightly
to the face.
The health department and hospital officials we spoke with said they
generally adopted these CDC guidelines for transmission control in
inpatient settings. Officials said one of the most effective practices
to contain SARS was frequent hand washing with soap and water. CDC
guidelines also allow the use of waterless alcohol-based hand rubs
after coming in contact with "suspect" or "probable" SARS patients or
their environments. Additionally, a hospital and a health department
official said careful cleaning of SARS patient rooms was an important
hygiene measure.
Inpatient facilities in the United States generally saw few SARS
patients. In New York and California, the hospital officials stated
that because of the small number of cases that were seen in each
hospital, usually only one or two at a time, the hospitals were able to
manage SARS patients in available isolation rooms. Because of the
greater prevalence of SARS in Toronto, all 22 acute care hospitals were
directed to have a SARS unit with negative pressure to the rest of the
hospital, individual rooms, and specific staff who only cared for SARS
patients. Toronto health department officials later were able to
designate four hospitals as SARS hospitals and direct all SARS patients
to these four facilities.
The use of face masks or N-95 respirators was highly recommended by
experts as an effective means of transmission control for SARS in
inpatient settings. In one study of health care workers who had
extensive contact with SARS patients in five Hong Kong hospitals,
researchers found that no health care worker who consistently used
either type of face covering became infected.[Footnote 10] Experts also
noted that the use of N-95 respirators and isolation rooms was
especially important for high-risk medical procedures, such as
intubation, where a patient's secretions are likely to be transformed
into a fine spray and spread for a longer distance than large
droplets.[Footnote 11] Officials cautioned, however, that there can be
difficulties in the use of N-95 respirators. One public health official
said that compliance may be limited in hospitals in several ways--
either staff has never been properly fitted for the respirators, or
some staff who were fitted many years ago should have a more recent
fitting. In Canada, Ontario's health ministry directed health care
workers in the province (which includes Toronto) to employ an
additional level of protective equipment when conducting high-risk
medical procedures that was not recommended in the United States. For
example, health care workers used a protective system that included a
hood, a full-face respirator, and a complete body covering such as
long-sleeved floor-length gowns and gloves.
The CDC guidelines for outpatient settings included the same standard
and contact precautions outlined for inpatient settings. Reflecting the
different types of facilities likely available in a physician office
compared to a hospital, for example, outpatient guidelines did not
advocate the use of specialized isolation rooms. Instead, for
outpatient settings, the guidelines advised health care personnel to
separate the potential SARS patient from others in a reception area as
soon as possible, preferably in a private room with negative pressure
relative to the surrounding area. At the same time, the guidelines said
that a surgical mask should be placed over the patient's nose and
mouth--if this was not feasible, the patient should be asked to cover
his or her mouth with a disposable tissue when coughing, talking, or
sneezing.
Transmission control guidelines for community settings incorporated
many of the same types of measures for containing the spread of SARS as
recommended for health care settings.[Footnote 12] CDC published SARS
transmission control guidelines for two community settings--the
workplace and households. The workplace guidelines recommended frequent
hand washing with soap and water or waterless alcohol-based hand rubs.
Along with handwashing, guidelines for household transmission control
included the following:
* 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, 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
during close contact with uninfected persons. If the patient is unable
to wear a surgical 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. Immediately after activities involving
contact with body fluids, gloves should be removed and discarded, and
hands should be washed. Gloves should not be washed or reused, and were
not intended to replace proper hand hygiene.
* SARS patients should avoid sharing eating utensils, towels, and
bedding with other members of the household, although these items could
be used by others after routine cleaning, such as washing or laundering
with soap and hot water.
* Frequent use should be made of common household cleaners for
disinfecting toilets, sinks, and other surfaces touched by patients
with SARS.
Exposure Management Used to Prevent SARS Spread:
Exposure management methods such as isolation and quarantine are
important infectious disease control measures. These measures were
particularly effective for SARS because of its long incubation period
during which infected individuals could be isolated before they become
contagious. In fact, experts stated that isolation of infected
individuals and quarantine measures used for exposed individuals were
critical for the containment of SARS.
Isolation of SARS infected individuals occurred in both health care and
home settings. In Toronto, patients were typically isolated in the
hospital--even in cases where individuals were not ill enough to need
hospitalization. During the height of Toronto's outbreak, all 22 acute
care hospitals were directed to have separate SARS units. On the other
hand, in the United States, individuals were hospitalized only if they
needed intensive medical treatment. According to an infectious disease
expert who consulted with the CDC, this practice was prompted by
concerns that grouping SARS cases together, such as in a hospital ward,
could increase the likelihood of spread to both health care workers and
other hospital patients.
For home isolation in New York City, each patient and contact was given
detailed information that included instructions on what to do if ill,
reminders of the importance of calling ahead before going to a
physician's office or other health care settings, and information on
how to travel to a health care setting without coming in contact with
others. These instructions also included guidelines for transmission
control measures to be used in the home. For all probable cases, the
New York City health department conducted a home assessment to ensure
that a SARS patient could be adequately isolated at home, which
included the need for such things as adequate ventilation and bathrooms
that would not be shared by noninfected individuals.
Quarantine of exposed individuals was based on different parameters,
depending on the number of "suspect" or "probable" SARS cases in the
community. CDC officials said the agency's guidance reflected the fact
that there was little or no transmission of SARS in the United States,
and therefore quarantine was less warranted because there were so few
cases in a community. CDC's guidance advised individuals who were
exposed but not symptomatic to monitor themselves for symptoms--such as
fever, a cough, and difficulty breathing, and further advised home
isolation and medical evaluation if symptoms began. CDC officials also
advised transfer to a hospital only if the illness became severe.
In contrast, Toronto, which experienced a high level of person-to-
person transmission, used a more conservative quarantine standard.
Individuals who did not have symptoms but had been in contact with SARS
infected individuals were ordered to stay in their homes and avoid
public gatherings for 10 days. Thousands people were asked to undergo
quarantine in their homes in the Toronto area. During the outbreak,
exposed Toronto health care workers were restricted to "work
quarantine"--they were only allowed to travel to and from work alone in
their vehicles, but they were not allowed to have visitors or visit
public places. Quarantine efforts in Toronto again required a high
level of resources. Daily phone calls required 60 staff per 1,000
people who were quarantined in the Toronto area; these staff worked 7
days a week to follow up with twice-daily calls to each individual.
Success in Implementing Infectious Disease Control Measures Depended on
Rapid and Frequent Communication:
According to health officials, rapid and frequent communications of
crucial information about SARS--such as the level of outbreak worldwide
and recommended infectious disease control measures--were vital
components of the efforts to contain the spread of SARS. Since March
2003, health organizations have shared extensive SARS-related
information and guidelines with health care workers. For example, WHO
scheduled numerous press briefings that updated the health community
about the status of international SARS containment and prevention
efforts. WHO, with CDC support, sponsored a videoconference broadcast
globally to discuss the latest findings of the outbreak and prevention
of transmission in health care settings (which was also available for
computer download). CDC activated its Emergency Operations Center and
devoted over 800 medical experts and support personnel worldwide to
provide round-the-clock coordination and response to the SARS outbreak.
CDC also had regular conference calls and information-sharing sessions
with various medical professional associations and state and local
health departments and laboratories.
At the state level, the California health department utilized the
California Health Alert Network to send e-mails with SARS information
(often based on CDC information) to all local health departments and
many hospitals and physicians. The New York City health department
hosted a symposium specifically for health care workers, to share the
latest available SARS information. Hospital officials we spoke with
also offered training seminars for their health care personnel on the
signs and symptoms of SARS, recommended screening questions, and
appropriate infectious disease control measures. Furthermore,
hospitals kept their patients informed about SARS via posters and
flyers throughout their facilities, especially in emergency room
waiting areas.
Health organizations maintained open and frequent communications in the
community setting to facilitate the containment of SARS. For example,
in a 2-week period early in the SARS outbreak, CDC conducted nine
telephone press conferences with the media to keep the public informed
about the latest SARS information, including numbers of "suspect" and
"probable" SARS cases, laboratory and surveillance findings, travel
advisories, and CDC's efforts nationally and worldwide. CDC also
distributed more than two million health alert notices to travelers
entering the United States from China, Hong Kong, Singapore, Taiwan,
Vietnam, or Toronto. These cards, printed in eight languages, asked
individuals to monitor their health for at least 10 days and to contact
their health care provider if they exhibited SARS symptoms. A state and
a local health official also stressed the importance of informing and
educating the general public in workplaces and schools on the signs and
symptoms of SARS, an effort which was intended to foster self-
identification, minimize panic, and assuage fears of being infected.
Public health officials also concurred that collaboration between
federal, state, and local health agencies as well as the medical
community was crucial in containing the spread of SARS. Through the
collaboration of all the appropriate players, coordination of
prevention activities could be maintained, roles could be identified
and assigned, available resources could be shared, and subsequent
evaluations could be conducted. For instance, the Toronto health
department maintained active communications with its local, provincial,
and national governments in regard to isolation and quarantine
practices, travel jurisdictions, and other SARS-related matters. The
health department published directives for all Toronto area health care
providers, outlining their SARS-related roles and responsibilities. The
health department also maintained ongoing contact with identified
liaisons at Toronto hospitals where SARS patients were hospitalized.
Furthermore, the city of Toronto activated its local emergency
operations center, which brought together emergency medical services,
police, and community neighborhood planners to work together to contain
SARS. Throughout Toronto's efforts, numerous briefings and
teleconferences were organized to keep all players abreast about the
latest SARS information in the community.
Federal, State, and Local Health Officials Are Preparing for a Possible
SARS Resurgence, But Implementing Plans May Pose Challenges if the
Resurgence Is Large-Scale:
While no one knows whether there will be a resurgence of SARS, federal,
state, and local health care officials we interviewed agree that it is
necessary to prepare for the possibility. As part of these
preparations, CDC, along with national associations that represent
state and local health officials, and others, is involved in developing
SARS-specific guidelines for using infectious disease control measures
and contingency response plans. In addition, these associations have
collaborated with CDC to develop a checklist of preparedness activities
for state and local health officials. Such preparation efforts also
improve the health care system's capacity to respond to other
infectious disease outbreaks, including those precipitated by
bioterrorism. However, implementing these plans may prove difficult due
to limitations in both hospital and workforce capacity. A large-scale
SARS outbreak could create overcrowding, as well as shortages in
medical equipment (including N-95 respirators) and in health care
personnel, who are at higher risk for infection due to their more
frequent exposure to a contaminated environment.
Federal, State, and Local Health Officials Are Preparing for the
Possibility of Future Outbreaks:
At the federal level, CDC has begun contingency planning for a SARS
outbreak, having convened a task force of infection control experts who
are responsible for developing SARS-specific guidelines and
recommendations, which address various infection control measures. The
task force plans to publish its guidelines and recommendations by
September 2003. CDC is collaborating with several professional
associations, such as the Council of State and Territorial
Epidemiologists, ASTHO, and NACCHO, to develop these response plans
that vary according to the prevalence of the disease and the type of
setting (i.e., health care or community) in which control measures need
to be implemented.
At the state and local levels, health departments are also in the
process of developing contingency response plans for SARS. To
facilitate this, ASTHO and NACCHO, in collaboration with CDC, published
a checklist for state and local health officials to use in the event of
a SARS resurgence. The SARS preparations have been modeled after a
checklist designed for pandemic influenza. The checklist encompasses a
broad spectrum of preparedness activities, such as legal issues related
to isolation and quarantine, strategies for communicating information
to health care providers, and suggestions for ensuring other community
partners such as law enforcement and school officials are prepared (see
app. I for a copy of the checklist).
In specific local preparedness efforts, California and New York, which
had the highest number of SARS cases in the United States, are also
preparing for a large-scale SARS outbreak. For example, California
health department officials said they were developing a plan for surge
capacity by considering staff rotations or details of health department
specialists to maintain a high level of response during a potential
SARS outbreak.[Footnote 13] Similarly, officials with the New York City
health department said they had created a formal procedure manual,
which outlines the roles of reallocated staff from various teams in the
department, to help contain a large-scale SARS outbreak.
Limitations in Hospital and Workforce Capacity Make Implementing
Infectious Disease Control Measures Difficult in the Event of a Large-
Scale SARS Outbreak:
While hospital officials we spoke with stated that they are taking
steps to ensure that they have the necessary preparations to address a
large-scale SARS outbreak, hospitals may still be limited in their
capacity to respond. Because of the inability to precisely determine if
someone has SARS, many people may be treated who do not have the virus.
In the event of a large-scale outbreak, this imprecision may result in
severe overcrowding in health care settings--especially if a SARS
resurgence occurs during a peak season for another respiratory disease
like influenza. This could strain the available capacity of hospitals.
For example, public health officials with whom we spoke said that in
the event of a large-scale SARS outbreak, entire hospital wards (along
with their staff) may need to be used as separate SARS isolation
facilities. Moreover, certain hospitals within a community might need
to be designated as SARS hospitals.
We recently reported that most hospitals lack the capacity to respond
to large-scale infectious disease outbreaks.[Footnote 14] Most
emergency departments have experienced some degree of crowding and
therefore, in some cases, may not be able to handle a large influx of
patients during a potential outbreak of SARS or another infectious
disease. Few hospitals have adequate staff, medical resources, and
equipment, such as N-95 respirators, needed to care for the potentially
large numbers of patients that may seek treatment.[Footnote 15] We
reported that in the seven cities we visited, hospital, state, and
local officials indicated that hospitals needed additional equipment
and capital improvements--including medical stockpiles, personal
protective equipment, quarantine and isolation facilities, and air
handling and filtering equipment--to enhance preparedness. According to
our survey of over 2,000 hospitals,[Footnote 16] the availability of
medical equipment varied greatly among hospitals, and few hospitals
reported having the equipment and supplies needed to handle a large-
scale infectious disease outbreak. Half the hospitals we surveyed had,
for every 100 staffed beds, fewer than 6 ventilators, 3 or fewer
personal protective equipment suits, and fewer than 4 isolation beds.
Workforce capacity issues may also hinder implementation of infectious
disease control measures. Health officials noted that there is a lack
of qualified and trained personnel, including epidemiologists, who
would be needed in the event of a SARS resurgence. This shortage could
grow worse if, in the event of a severe outbreak, existing health care
workers became infected as a result of their more frequent exposure to
a contaminated environment or became exhausted working longer hours.
Workforce shortages could be further exacerbated because of the need to
conduct contact tracing. According to WHO officials, an individual
infected with SARS came into contact with, on average, 30 to 40 people
in Asian countries--all of whom had to be contacted and informed of
their possible exposure. In contrast, New York City health department
officials said that infected individuals came into contact with 4
people on average.
In addition, the monitoring of individuals placed under isolation and
quarantine may strain resources if widespread isolations and
quarantines are needed. For example, follow-up with isolated or
quarantined individuals requires significant resources. Officials of
the New York City Department of Health and Mental Hygiene said that
they made home visits to SARS cases when officials became concerned
that these individuals were not following infection control measures or
were not remaining in their homes. Similarly, Canadian public health
officials said that they, and in some cases Canadian police, made home
visits to check compliance with quarantine orders. These officials also
described the difficulty in providing necessary resources (food,
medicines, masks, and thermometers) to individuals under isolation or
quarantine. In Canada, police and the Red Cross had to help deliver
food to those under isolation or quarantine.
Concluding Observations:
The global spread of SARS was contained through an unprecedented level
of international scientific collaboration and the use of well-
established infection control measures that have been used effectively
in the past to control diseases. Although questions remain about SARS,
especially about the ways it can be transmitted, many lessons were
learned that could be helpful to the United States in the event of a
resurgence. Lessons to carry forward are the importance of early
identification of infected individuals and their contacts, the
effectiveness of safety precautions to control transmission and ensure
the protection of health care workers, and the need to use, in some
cases, isolation and quarantine. Swift and unfettered communication
among heath care workers, public health officials, government agencies,
as well as the public provided the essential backbone to support
ongoing efforts to contain the disease.
Although SARS is currently believed to be contained, now is the time to
prepare for the possibility of a future outbreak. Some preparations are
already underway and encompass, in large part, approaches similar to
those for pandemic influenza and are also part of general bioterrorism
preparedness. Worldwide disease surveillance would facilitate prompt
identification of a resurgence of SARS, allowing rapid implementation
of infectious disease control measures that would reduce both the
spread of SARS and the risk of a large outbreak. Should a large-scale
outbreak occur in the near term, limitations in the capacity of our
nation's health system to undertake effective and rapid implementation
of infectious disease control measures could prove problematic. A major
SARS outbreak would necessitate rapid escalation of infectious disease
control resources including health care workers, emergency room and
hospital capacity, and the requisite control and support equipment.
Mr. Chairman, this completes my prepared statement. I would be happy to
respond to any questions you or other Members of the Subcommittee may
have at this time.
Contact and Staff Acknowledgments:
For more information regarding this testimony, please contact Marjorie
Kanof at (202) 512-7101. Bonnie Anderson, Karen Doran, John Oh,
Danielle Organek, and Krister Friday also made key contributions to
this statement.
[End of section]
Appendix I: SARS Preparedness Checklist:
[See PDF for image]
[End of section]
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FOOTNOTES
[1] U.S. General Accounting Office, SARS Outbreak: Improvements to
Public Health Capacity Are Needed for Responding to Bioterrorism and
Emerging Infectious Diseases, GAO-03-769T (Washington, D.C.: May 7,
2003).
[2] The coronavirus is one of a group of viruses that are responsible
for some but not all common colds. They are so named because their
microscopic appearance is that of a virus particle surrounded by a
crown.
[3] Close contact is usually defined as having cared for, lived with,
or having direct contact with bodily secretions of an infected
individual.
[4] See Centers for Disease Control and Prevention, Department of
Health and Human Services, Updated Interim U.S. Case Definition for
Severe Acute Respiratory Syndrome (SARS) (Atlanta, Ga.: July 16, 2003).
[5] The last date for illness onset is 10 days (i.e., one incubation
period) after removal of a CDC travel alert. To be considered a suspect
case, an individual's travel would have occurred on or before the last
date the travel alert was in place.
[6] Mechanical ventilation involves artificial ventilation of the lung
using means external to the body. A mechanical ventilator is a machine
that generates a controlled flow of gas (a mixture of oxygen and air)
into a patient's airways.
[7] Additionally, on July 16, 2003, CDC revised the case definition to
exclude individuals with negative test results for SARS coronavirus.
This resulted in 207 previously identified SARS cases (169 suspect
cases and 38 probable cases) being removed from the count of SARS cases
in the United States.
[8] See Centers for Disease Control and Prevention, Department and
Health and Human Services, Updated Interim Domestic Infection Control
Guidance in the Health-Care and Community Setting for Patients with
Suspected SARS (Atlanta, Ga.: May 1, 2003).
[9] Negative pressure rooms generally are private rooms in which air
flow is from the hallway into the room, and then outdoors.
[10] See W.H. Seto, et.al., Effectiveness of precautions against
droplets and contact in prevention of nosocomial transmission of severe
acute respiratory syndrome (SARS), The Lancet (Vol. 361, May 3, 2003),
pp. 1519-20.
[11] Generally, intubation is the introduction of a tube into an
individual's airway to facilitate breathing.
[12] See Centers for Disease Control and Prevention, Department of
Health and Human Services, Interim Guidance on Infection Control
Precautions for Patients with Suspected Severe Acute Respiratory
Syndrome (SARS) and Close Contacts in Households (Atlanta, Ga.: Apr.
29, 2003).
[13] Surge capacity is the ability of the health care system to handle
a large number of patients.
[14] U.S. General Accounting Office, SARS Outbreak: Improvements to
Public Health Capacity Are Needed for Responding to Bioterrorism and
Emerging Infectious Diseases, GAO-03-769T (Washington D.C.: May 7,
2003).
[15] Shortages in N-95 respirators occurred during the SARS outbreak
because of the high demand. CDC officials said that shortages in the
United States may have been due to high demand in other countries,
particularly when WHO recommended that health care workers in all
affected countries use N-95 respirators.
[16] Between May and September 2002, we surveyed over 2,000 short-term,
nonfederal general medical and surgical hospitals with emergency
departments located in metropolitan statistical areas. (See U.S.
General Accounting Office, Hospital Emergency Departments: Crowded
Conditions Vary among Hospitals and Communities, GAO-03-460
(Washington, D.C.: Mar. 14, 2003) for information on the survey
universe and development of the survey.) For the part of the survey
that specifically addressed hospital preparedness for mass casualty
incidents, we obtained responses from 1,482 hospitals, a response rate
of about 73 percent.
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