3 figures, 1 table omitted
CDC continues to work with state and local health departments, the World
Health Organization (WHO), and other partners to investigate cases of severe
acute respiratory syndrome (SARS). During November 1, 2002–April 30,
2003, a total of 5,663 SARS cases were reported to WHO from 26 countries,
including the United States; 372 deaths (case-fatality proportion: 6.6%) have
been reported.1 This report updates information
on reported SARS cases among U.S. residents and provides an overview regarding
CDC's issuance of travel alerts and advisories.
As of April 30, a total of 289 SARS cases were reported to CDC from
38 states, of which 233 (81%) were classified as suspect SARS, and 56 (19%)
were classified as probable SARS (more severe illnesses characterized by the
presence of pneumonia or acute respiratory distress syndrome).2 Laboratory
testing to evaluate infection with the SARS-associated coronavirus (SARS-CoV)
has been completed for 60 cases. Laboratory-confirmed infection, based on
detection of antibody to SARS-CoV in serum or evidence of virus in clinical
specimens by reverse transcriptase polymerase chain reaction analysis, has
been identified in six patients; all were probable cases, as described previously.3,4 Negative findings (i.e., the
absence of antibody to SARS-CoV in convalescent serum obtained >21 days after
symptom onset) have been documented for 54 cases (41 suspect and 13 probable).
Of the 56 probable SARS patients, 37 (66%) were hospitalized, and two
(4%) required mechanical ventilation. One patient (2%) was a health-care worker
who provided care to a SARS patient, and one (2%) was a household contact
of a SARS patient. The remaining 54 (96%) probable SARS patients (including
the six patients with positive SARS-CoV laboratory results) had traveled to
mainland China; Hong Kong Special Administrative Region, China; Singapore;
Hanoi, Vietnam; or Toronto, Canada.
As of April 30, the SARS outbreak control strategy for the United States
has included issuance of travel alerts and advisories and distribution of
health alert notices to travelers arriving from areas with SARS to facilitate
early identification of imported cases. Current travel alerts (Hanoi and Toronto)
and advisories (Hong Kong, Taiwan, mainland China, and Singapore) can be found
Health alert notices, which have been translated into seven languages
(Chinese [Simplified and Traditional], French, Japanese, Korean, Spanish,
and Vietnamese), inform the returning traveler of potential exposure to cases
of SARS. They alert travelers to the symptoms of SARS and to promptly seek
medical attention if symptoms develop. Travelers should call their health-care
provider in advance to report recent travel to areas with SARS. The notices
also provide information and additional instructions for physicians.
During March 16–April 29, CDC distributed 735,370 health alert
notices to travelers arriving from the areas with SARS in Southeast Asia at
22 airports at points of entry into the United States. As of April 26, health
alert notices have been distributed at the Lester B. Pearson International
Airport in Toronto to embarking U.S. passengers destined for 58 airports in
the United States and overland crossings of the U.S.-Canadian border. In addition,
copies of health alert notices have been provided to cargo and cruise ship
lines for distribution to crew and passengers.
As of April 30, 96% of probable U.S. SARS cases have occurred among
international travelers, with only two instances of secondary transmission
associated with these cases.5 Since the
previous SARS update,4 no additional laboratory-confirmed
cases have been identified. The collection and testing of convalescent serum
is critical for laboratory confirmation of cases that have undetermined laboratory
CDC issues travel alerts and advisories based on evidence of transmission
in areas with SARS, translocation of the disease, and the effectiveness of
local prevention efforts. The quality of local disease surveillance and the
accessibility of medical care in areas with SARS are additional considerations.
The definitions of travel alerts and advisories are available at http://www.cdc.gov/ncidod/sars/travel_alertadvisory.htm.
Travel alerts and advisories are notifications that an outbreak of a
disease is occurring in a geographic area outside of the United States. A
travel alert, the lower-level notice, provides information about the disease
outbreak and informs travelers and resident expatriates of ways to reduce
their risk for infection. An alert does not include a recommendation against
nonessential travel to the area. When the health risk for travelers is thought
to be high, a travel advisory is issued that recommends against nonessential
travel to the area. Travel advisories are intended to reduce the number of
travelers to areas with SARS and the risk for translocating disease to other
In response to the SARS outbreak, CDC provided health alert notices
to travelers returning from areas with SARS to promptly detect potential cases
of SARS. These health alert notices also helped raise awareness of SARS among
health-care providers and the general public.
Travel alerts and advisories are disseminated through media advisories,
press briefings, e-mail notifications, and State Department advisories. They
are posted routinely on the CDC Travelers' Health website at http://www.cdc.gov/travel. Health alert notices can be found at http://www.cdc.gov/ncidod/sars/travel_alert.htm.
Update: Severe Acute Respiratory Syndrome—United States, 2003. JAMA. 2003;289(19):2495–2498. doi:10.1001/jama.289.19.2495
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