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SARS information continually updated on Web
by Robert S. Baltimore, M.D., FAAP

The recent outbreak of sudden acute respiratory syndrome (SARS) has prompted the Academy to evaluate what is known about the disease, particularly with regard to children. Information about SARS is evolving rapidly, and pediatricians are encouraged to access the Web sites listed below for up-to-date information.

Evolution of SARS
On Feb. 11, the Chinese Ministry of Health notified the World Health Organization (WHO) that 305 cases of acute respiratory syndrome of unknown etiology had occurred in six municipalities in Guangdong province in southern China from Nov. 16, 2002, to Feb. 9, 2003. During late February 2003, an outbreak of a similar respiratory illness was reported in Hong Kong among workers at a hospital.

On March 12, WHO issued a global alert about the outbreak and instituted worldwide surveillance for SARS. Subsequently, there has been spread to other countries, but at this time all cases can be traced to contact with individuals from Asian countries. However, a few of these cases appear to be the result of community spread from an individual whose illness could be traced to Asia.

The agent of the disease appears from early reports to be a member of the coronavirus family, but this is still being investigated. There is no proven effective treatment for this virus. Although various therapies including using intravenous ribavirin and steroids have been administered to SARS patients, the efficacy of these therapies has not been determined. For treatment of suspected cases, consultation with an infectious diseases expert should be sought.

Current case definition
On the basis of these early reports, the following case definition was developed:

Measured temperature = 100.4F (>38 C) and
one or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, hypoxia, or radiographic findings of either pneumonia or acute respiratory distress syndrome) and
travel within 10 days of onset of symptoms to an area with documented or suspected community transmission of SARS. or Close contact within 10 days of onset of symptoms with either a person with a respiratory illness who traveled to a SARS area or a person known to be a suspect SARS case.
This case definition will be updated as new information becomes available. (See Centers for Disease Control and Prevention (CDC) Web site below.)

In the first approximately 2,300 cases of individuals who met the case definition, the fatality rate was about 4% and infections in children were uncommon (approximately 2% of SARS cases in the Canadian data, 14% in early U.S. data). It is unclear, so far, if the small number of children represents host resistance to infection, illness too mild to come to medical attention or lack of contact with infected individuals.

WHO, CDC and other public health agencies worldwide are continuing to investigate this multicountry outbreak.

The number of SARS cases and countries reporting such cases continue to increase worldwide. In the absence of a complete understanding of SARS' etiology and how SARS is transmitted, efforts to limit transmission in the United States have focused on early identification of potential cases through surveillance and implementation of infection-control measures in health care settings and the community. Infection-control precautions, which include standard, contact and airborne precautions, should be instituted immediately for people who meet the case definition. Materials sent to diagnostic laboratories require high-level precautions against dissemination. Specimens require special handling, and laboratories must be contacted in advance of sending any specimens from suspect cases in order to apply the appropriate precautions.

CDC has developed interim infection-control guidelines for use in U.S. health care and household settings. These recommendations are based on experience in the United States to date and will be revised as more information becomes available. Infection-control practitioners and clinicians providing medical care for patients with suspected SARS should consult these guidelines frequently to keep current with recommendations.

Health care providers of patients whose illness is consistent with the case definition for SARS should continue diagnostic evaluation for other causes of respiratory tract illness and, when appropriate, empiric therapy including agents active against organisms associated with community-acquired pneumonia of uncertain etiology, including both typical and atypical respiratory tract pathogens.

WHO and CDC have issued travel advisories recommending that persons consider postponing non-essential or elective travel to affected areas until further notice. Persons who recently have traveled to affected areas are urged to: monitor their health for 10 days after return; seek medical care if they develop fever and cough or difficulty breathing within 10 days of travel; and inform their health care providers about recent travel to regions where SARS cases have been reported. Ten days appears to be the outside limit for the incubation period of SARS (two to 10 days).

To detect possible SARS cases among travelers returning to the United States from these areas, CDC and state and local health authorities have implemented enhanced surveillance. Clinicians and public health officials are requested to report suspected cases of SARS to their state health departments.

Current information on SARS, including case definition, infection-control practices, diagnostic evaluation, treatment, reporting and travel advisories can be found on the CDC Web site at www.cdc.gov/ncidod/sars/exposuremanagement.htm. Updated case counts and additional information also are available on the WHO Web site at www.who.int.

The following points will be helpful in speaking with parents and schools posing SARS-related questions:
  • Children do not need to restrict their activities except as related to official travel alerts. For travel advisories, access www.travel.state.gov.
  • Children who have been exposed to individuals who are not ill but have traveled to areas where SARS is occurring do not require isolation.
  • Children who have been exposed to an ill individual who is suspected of having SARS at the time of the exposure or children who have traveled to an area where SARS is occurring (e.g., Toronto, Hong Kong, mainland China, Singapore) should be evaluated based on the following:
    • If well, parents should self-monitor the child's condition for fever or respiratory tract illness. At present, attendance at child care or school is not restricted, although this may change as new information becomes available.
    • If the child is not well, parents should contact their pediatrician and the child be isolated at home, according to procedures established by public health authorities.
    • If a child is not well and experiencing hypoxia, shortness of breath or breathing difficulty, he/she should be hospitalized and health care workers informed before the admission so SARS precautions can be initiated. (See CDC Web site.)
Dr. Baltimore is a member of the AAP Committee on Infectious Diseases.


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