Letter to physicians regarding SARS

January 2004

Dear Doctor,

The 2003 outbreak of severe acute respiratory syndrome (SARS) demonstrated the rapid global spread of an infectious disease and its tremendous impact on certain communities, especially healthcare facilities. It is not known if SARS will emerge in New York State, but healthcare and public health officials must prepare for the possible emergence to minimize the morbidity, mortality and disruption due to SARS. Thus, I am writing to provide you with important SARS guidance, including:

  • Implementing "standard respiratory precautions" in healthcare settings,
  • reporting potential SARS cases,
  • evaluating and managing potential SARS patients,
  • arranging for laboratory testing for SARS-associated coronavirus (SARS-CoV); and
  • staying informed about SARS.

This guidance is based on the Centers for Disease Control and Prevention’s (CDC) Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) and other materials, which are posted on CDC’s SARS website at www.cdc.gov/ncidod/sars.

I. Implementing "Standard Respiratory Precautions" in Healthcare Settings

SARS provides a reminder of the risks of nosocomial transmission of respiratory pathogens and an opportunity to improve overall infection control in healthcare facilities. All healthcare facilities (e.g., hospitals, emergency departments, clinics, doctor’s offices) need to re-emphasize the importance of basic infection control measures for the control of febrile respiratory illnesses. In addition, all healthcare facilities should implement the "standard respiratory precautions" (also referred to by CDC as "respiratory hygiene/cough etiquette") outlined in Attachment 1 to help limit the transmission of respiratory pathogens in healthcare settings.

II. Reporting Potential SARS Cases

In April 2003, on an emergency basis, SARS was added to the New York State reportable disease list (Attachment 2). Physicians should immediately report any potential SARS cases (as defined by the reporting criteria below and in Attachment 3) to the local health department (LHD). SARS reporting criteria will be based on the level of SARS activity worldwide. The two categories of SARS activity are (1) absence of SARS-CoV transmission worldwide, and (2) presence of SARS-CoV transmission in the world.

Note: At the time of writing this letter, the World Health Organization and the Chinese Ministry of Health have announced one laboratory-confirmed case of SARS in Guangdong Province, China. Because this is an isolated case with no evidence of person-to-person transmission, the CDC and New York State Department of Health guidelines for SARS surveillance in the absence of SARS-CoV transmission (as outlined below) still apply. However, the situation is rapidly evolving and providers should regularly check the websites listed in Section V for the most current information on SARS.

SARS Reporting Criteria: Absence of SARS-CoV Transmission Worldwide.

In the absence of SARS transmission worldwide, surveillance is aimed at early detection of cases among individuals likely to be first affected by the re-emergence of SARS, including healthcare workers and travelers to mainland China, Hong Kong, or Taiwan. Surveillance is focused on persons being hospitalized with severe respiratory illness, characterized by radiographic evidence of pneumonia or acute respiratory distress syndrome (ARDS) of unknown etiology.

Medical providers should screen all patients being admitted to the hospital with pneumonia or ARDS for risk factors for possible exposure to SARS-CoV, including recent travel, employment history, and/or exposure to an ill traveler or person who was recently diagnosed with pneumonia. Providers should immediately report to the LHD any patient who meets the reporting criteria detailed in Attachment 3.

SARS Reporting Criteria: Presence of SARS-CoV Transmission in the World.

If the re-emergence of SARS is documented with person-to-person transmission, the likelihood that persons with respiratory infections may be infected with SARS-CoV will increase significantly. Thus, surveillance activities should be expanded to include non-hospitalized persons with fever or respiratory symptoms.

Medical providers should screen all patients presenting with fever or respiratory symptoms for risk factors for possible exposure to SARS-CoV, including recent travel history, employment history, or history of exposure to someone who may have SARS. Providers should immediately report to the LHD any patient who meets the reporting criteria detailed in Attachment 3.

III. Evaluating and Managing Potential SARS Patients

Similar to the SARS reporting criteria described above and in Attachment 3, the Centers for Disease Control and Prevention’s algorithms for evaluating potential SARS patients are based on the level of SARS activity worldwide. When there is no known SARS-CoV transmission in the world, the diagnosis of SARS-CoV disease should be considered only in patients who require hospitalization for radiographically confirmed pneumonia or ARDS and who have a risk factor for possible exposure to SARS-CoV (i.e., the patient meets the SARS reporting criteria). Patients who meet the SARS reporting criteria should be evaluated according to the algorithm in Attachment 4. All patients admitted to the hospital with pneumonia or ARDS should be placed empirically on droplet precautions. If there is an increased index of suspicion for SARS-CoV disease based on clinical or epidemiologic criteria (e.g., while traveling, visited a healthcare setting or had close contact with a person hospitalized for a respiratory infection), the patient should immediately be placed on SARS isolation (airborne) precautions (www.cdc.gov/ncidod/sars/ic.htm).

Once SARS-CoV transmission has been documented in the world, screening for possible exposure to SARS-CoV should be conducted on all patients with fever or respiratory symptoms. Patients who meet the SARS reporting criteria when there is documented SARS activity should be evaluated and managed according to the algorithm in Attachment 5.

IV. Arranging for SARS-CoV Laboratory Testing by the NYSDOH

The first point of contact for a clinician to arrange for SARS-CoV testing is the LHD. If the LHD cannot be reached, call the NYSDOH Bureau of Communicable Disease Control at 518-473-4436 during business hours, or the NYSDOH Duty Officer after-hours at 1-866-881-2809. For patients who meet the case definition and whose case history has been reviewed by the local and/or State health departments, the NYSDOH Wadsworth Center laboratory will test for infection with SARS-CoV using both a reverse-transcriptase PCR (RT-PCR assay) and an enzyme-linked immunoassay (EIA). These tests have been developed by the CDC.

Most patients in the early stages of SARS illness have a low titer of virus in respiratory and other secretions and require time to mount an antibody response. Thus, the likelihood of detecting SARS-CoV infection is increased if multiple specimens (e.g. stool, serum, and respiratory tract specimens) are collected at several times during the course of illness. Attachment 6 details which specimens to collect and the optimal method and timing of collection.

V. Keeping Informed about SARS

Guidelines and recommendations for SARS reporting, infection control, and clinical and laboratory evaluation are evolving. If SARS recurs, providers will need to stay informed about current SARS activity, reporting criteria, case definitions, and case evaluation and management protocols, which may change frequently. Providers should regularly check the following websites for the most current information on SARS:

Centers for Disease Control and Prevention:   www.cdc.gov/ncid/sars
World Health Organization:   www.who.int/en
New York State Department of Health:   www.health.state.ny.us

In addition, providers should register for a NYSDOH Health Provider Network (HPN) account. The HPN is a secure, internet-based communication system that the NYSDOH uses as its principal means for disseminating and gathering important and sensitive information on urgent public health issues. To sign-up for an HPN account, please call 1-866-529-1890.

Thank you for your ongoing assistance in this critical public health preparedness effort.


Antonia C. Novello, M.D., M.P.H., Dr.P.H.
Commissioner of Health


Attachment 1: Standard Respiratory Precautions for Healthcare Facilities
Attachment 2: New York State Department of Health List of Reportable Communicable Diseases
Attachment 3: Reporting Potential SARS Cases
Attachment 4: Algorithm for the Evaluation and Management of Patients Hospitalized With Radiographic Evidence of Pneumonia in the Absence of SARS-CoV Transmission Worldwide
Attachment 5: Algorithm for the Management of Patients with Fever or Respiratory Symptoms When SARS-CoV Transmission is Occurring in the World
Attachment 6: Laboratory Testing for SARS at the NYSDOH Wadsworth Center