Questions About Severe Acute Respiratory Syndrome (SARS)

Revised May 13, 2003

In an attempt to help provide factual information about recent reports regarding the atypical pneumonia occurring in Canada, China, Hong Kong Special Administrative Region of China, Indonesia, Philippines, Singapore, Thailand, and Vietnam, the Disease Prevention Education division of the American Red Cross has compiled the following information from several federal agencies. This information has been compiled for general information purposes only and anyone using the information should not represent the American Red Cross as an authority in this area.

Introduction: A respiratory illness has emerged in recent months in Canada, China, Hong Kong Special Administrative Region of China, Indonesia, Philippines, Singapore, Thailand, and Vietnam, presenting a worldwide public health concern.

Background: This atypical pneumonia has been named Severe Acute Respiratory Syndrome (SARS) by World Health Organization (WHO). SARS is an infectious disease of the respiratory system characterized by atypical inflammation of the lungs (pneumonia). Scientists at CDC and other laboratories have detected a previously unrecognized coronavirus in patients with SARS. This new coronavirus is the leading hypothesis for the cause of SARS.

SARS appears to be primarily spread from person-to-person through droplet transmission when in direct close contact with a person with SARS. Potential ways in which SARS can be spread include touching the skin of other people or objects that are contaminated with infectious droplets and then touching your eye(s), nose, or mouth. SARS is an emerging disease. Knowledge about its clinical behavior, response to treatment, and modes and risks of transmission are continually evolving.

Early symptoms in patients with SARS have included fever (>100°F), muscle aches, dry cough, shortness of breath, or difficulty breathing. The illness usually begins with a fever (measured temperature greater than 100.4°F [>38.0°C]) which is sometimes associated with chills or other symptoms, including headache, general feeling of discomfort and body aches. Some people also experience mild respiratory symptoms at the outset.

After 2 to 7 days, SARS patients may develop a dry, nonproductive cough that might be accompanied by or progress to the point where insufficient oxygen is getting to the blood. Ten percent of 20 percent of SARS cases may progress to requiring the use of a respirator. No specific treatment recommendations can be made at this time, however, medical personnel is instructed to treat general clinical signs. CDC currently recommends that patients with SARS receive the same treatment that would be used for any patient with serious community-acquired atypical pneumonia. The virus suspected to be the cause of SARS (coronavirus) is being tested against various antiviral drugs to see if an effective treatment can be found.

Geographic Distribution*: As of May 14, 2003, WHO has received reports of 7628 cases of Severe Acute Respiratory Syndrome (SARS) with 587 deaths. In the United States, as of May 13, 2003, there are currently 345 cases under investigation representing 281 suspect cases and 64 probable cases.

*It is anticipated that the geographic distribution information can change. For the most up-to-date disease surveillance, please check case information at http://www.cdc.gov/od/oc/media/sars.htm.

Questions & Answers

Q. Where did Severe Acute Respiratory Syndrome (SARS) come from?
A. SARS is an infectious disease of the respiratory system characterized by an atypical inflammation of the lungs (pneumonia). Scientists at CDC and other laboratories have detected a previously unrecognized coronavirus in patients with SARS. This new coronavirus is the leading hypothesis for the cause of SARS.

Q. What is atypical pneumonia?
A. Pneumonia is an infection of one or both lungs which is usually caused by a bacteria, virus, or fungus. Atypical pneumonias appear different from ‘classic’ presentations of this infection and may be more viral in nature. Pneumonia is the sixth leading cause of death in the United States.

Q. What is coronavirus?
A.Coronaviruses are a group of viruses that are a common cause of mild to moderate upper-respiratory illness in humans. They are associated with respiratory, gastrointestinal, liver and neurologic disease in animals. These viruses have a halo or crown-like (corona) appearance when viewed under a microscope.

Q. How is SARS transmitted?
A.The disease appears to be primarily spread from person to person through droplet transmission when in direct close contact with a person with SARS. Direct close contact in this case is defined as having cared for, having lived with, or having had direct contact with respiratory secretions and body fluids of a person with SARS. For example, when someone sick with SARS coughs or sneezes droplets onto themselves, other people or nearby surfaces. Potential ways in which SARS can be spread include touching the skin of other persons or objects that become contaminated with infectious droplets and then touching your eyes, nose or mouth.

It also is possible that SARS can be spread more broadly through the air or by other ways that are currently not known.

Q. What is the difference between droplet and airborne transmission of viruses?
A. Droplet transmission refers to the spread of viruses contained in relatively large respiratory droplets that people project when they cough or sneeze. Because of their large size, droplets travel only a short distance (usually 3 feet or less) before they settle. Droplet transmission can occur either directly when droplets are inhaled by another person, or indirectly when droplets land on an object or surface (such as a doorknob or telephone) which is then touched by another individual. Common-cold viruses (like rhinovirus) are typically spread by droplets.

Airborne transmission means that the virus is spread by very small respiratory aerosol (fine mist) particles or dust, which can be breathed in by another person. Small aerosol particles can remain in the air and travel over a greater distance than larger respiratory droplets. Examples of viruses spread by the airborne route are influenza and measles viruses.

Q. What does "close contact" mean?
A.The primary way that SARS appears to spread is by close person-to-person contact. Close contact might occur when between people live together in the same household or if someone is providing care to a SARS patient. Examples include kissing or embracing, sharing eating or drinking utensils, engaging in close conversation (within 3 feet), conducting a physical examination, and any other direct physical contact between people. Close contact does not include activities such as walking by a person or sitting across a waiting room or office for a brief period of time.

Q. How can I protect myself against SARS?
A.There are some common-sense measures that apply to many infectious diseases and you can take to prevent the spread of SARS. The most important is frequent hand washing with soap and water or use of alcohol-based hand rubs. In addition, you should avoid touching your eyes, nose, and mouth with unclean hands and encourage people around you to cover their nose and mouth with a tissue when coughing or sneezing.

Q. How long do coronaviruses survive in the environment?
A. Preliminary studies in some research laboratories suggest that the virus may survive in the environment for several days. The length of time that the virus survives likely depends on a number of factors and conditions. Factors could include the type of material or surface the virus is found on or the body fluid containing the virus and environmental conditions such as temperature or humidity. Researchers at CDC and other institutions are designing standardized experiments to measure how long the SARS coronavirus (SARS Co-V) can survive in situations that simulate natural environmental conditions.

Data on survival of SARS Co-V outside of the human body emphasize the importance of frequent handwashing with soap and water or use of alcohol-based hand rubs if hands are not visibly dirty.

Q. Should I wear a surgical mask to protect myself from getting SARS?
A. CDC does not recommend routine use of surgical masks when people are in public to prevent SARS.

Q. Are there any times when a surgical mask should be worn to prevent the spread of SARS?
A. People who have -- or think they might have -- SARS should cover their mouth and nose with a tissue when coughing or sneezing. If possible, they also should wear a surgical mask during close contact with people who are not infected (for example, household members) to prevent the spread of infectious droplets. When a person with SARS is unable to wear a surgical mask, household members should wear surgical masks when in close contact with the patient. Surgical masks should fit snugly around the mouth and nose. Masks are intended for use by one person only and should not be shared. Masks should be discarded when soiled or moist; changing masks daily is a good rule of thumb. Hand hygiene should be performed after handling a soiled mask.

Q. What are the symptoms of SARS?
A. The illness usually begins with a fever (measured temperature greater than 100.4°F [>38.0°C]) which is sometimes associated with chills or other symptoms, including headache, general feeling of discomfort and body aches. Some people also experience mild respiratory symptoms at the outset.

After 2 to 7 days, SARS patients may develop a dry, nonproductive cough that might be accompanied by or progress to the point where insufficient oxygen is getting to the blood.

Q. What is the incubation period (i.e., time from infection to onset of disease symptoms) for SARS?
A. Usually 2 to 7 days with 3-5 days being more common. Some isolated cases have experienced incubation periods of as long as 10 days.

Q. Is there a test for SARS?
A. Several new laboratory tests can be used to detect the SARS-associated coronavirus (SARS-CoV). Tests looking specifically for the body’s response (antibody reaction) to the presence of coronavirus can be performed. Other tests of clinical specimens, including serum, stool and nasal secretions can be used to identify the presence of genetic material specific for SARS-CoV as well. Finally, test involving growing and isolating the actual virus have both been used to detect the presence of SARS-CoV. CDC has begun to make coronavirus testing materials available to state health departments and other laboratories.

Q. What should I do if I think I have symptoms of SARS?
A. If you are ill with a fever of over 100.4 °F (>38.0°C) that is accompanied by a cough or difficulty breathing, or that progresses to a cough and/or difficulty breathing, you should consult a health care provider. To help your health care provider make a diagnosis, tell them about any recent travel to regions where cases of SARS have been reported and whether you were in contact with someone who had these symptoms.

Q. What has CDC recommended to prevent transmission of SARS in households?
A. CDC has developed interim infection control recommendations for patients with suspected SARS in the household. The basic precautions include 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, all members of the household with a SARS patient should carefully follow recommendations for hand hygiene, such as frequent hand washing or the use of alcohol-based hand rubs.
• 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. However, 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 are 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 can be used by others after routine cleaning, such as washing or laundering with soap and hot water. Coronaviruses can survive in the environment for as long as three hours.
• Common household cleaners are sufficient for disinfecting toilets, sinks, and other surfaces touched by patients with SARS, but the cleaners must be used frequently.

Other members of the household need not restrict their outside activities unless they develop symptoms of SARS, such as a fever or respiratory illness.

Q. What kills the virus that causes SARS?
A. Right now, there are no disinfectant products registered by the U.S. Environmental Protection Agency (EPA) for use on environmental surfaces that are specifically listed as having the ability to kill the new coronavirus associated with SARS. However, related viruses that have similar physical and biochemical properties can be killed with bleach, ammonia or alcohol, or cleaning agents containing any of these disinfectants. Cleaning agents should be used according to the manufacturer's instructions.

Q. How should SARS be managed in the workplace?
A. Workers, who in the last 10 days have traveled to a known SARS area, or have had close contact with a co-worker or family member with suspected or probable SARS could be at increased risk of developing SARS and should be on the alert for the development of fever (greater than 100.4° F) or respiratory symptoms (e.g., cough or difficulty breathing). If these symptoms develop, do not go to work, school, or other public areas and seek evaluation by a health-care provider and practice infection control precautions recommended for the home or residential setting; be sure to contact your health-care provider beforehand to let them know you may have been exposed to SARS.

Q. What is the treatment for SARS?
A. CDC currently recommends that patients with SARS receive the same treatment that would be used for any patient with serious community-acquired atypical pneumonia of unknown cause. Symptoms should be treated by adequately protected health professionals. The coronavirus is being tested against various antiviral drugs to see if an effective treatment can be found.

Q. What is the status of the SARS outbreak in the United States?
A. In the United States, cases of SARS continue to be reported primarily among people who traveled to affected areas; a small number of other people have gotten sick after being in close contact with (that is, having cared for or lived with) a SARS patient while in the United States. Currently, there is no evidence that SARS is spreading more widely in the community in the United States.

To minimize the risk for SARS among U.S. residents, the public health system is taking careful and thorough precautions to stop the spread of SARS. People who are suspected of having SARS are being isolated from others and getting care. People arriving from affected parts of the world (who might have been exposed to SARS) are receiving information about SARS and instructions on what they should do if they become ill. SARS patients and their contacts are being monitored to help prevent spread of the disease.

Q. How many cases of SARS have occurred in the U.S.?
A. No cases have been confirmed to date in the United States; however, as of May 13, 2003, there were 345 cases, representing 281 suspect cases and 64 probable cases. For information on US cases see www.cdc.gov/od/oc/media/sars.htm.

Q. What is the difference between a “probable” SARS case and a “suspect” SARS case?
A. Suspect SARS cases have fever, respiratory illness, and recent travel to an affected area with community transmission of SARS and/or contact with a suspect SARS patient. Probable cases meet the criteria for a suspect case and also have evidence (e.g., chest X-ray) of pneumonia or respiratory failure.

Q. Are there any travel restrictions related to SARS?
A. At this time there are no travel restrictions in place that are directly related to SARS. However, a CDC travel advisory recommends that individuals who are planning nonessential or elective travel to mainland China, Hong Kong and Taiwan may wish to postpone their trip until further notice. CDC also has issued travel alerts for Singapore; Hanoi, Vietnam; and Toronto, Canada, to recommend that U.S. travelers to any of these places observe precautions to safeguard their health. For additional information about travel advisories, check CDC's Travelers' Health site, which will be updated as necessary.

Q Is there any reason to think SARS is or is not related to bio-terrorism?
A. Information currently available about SARS indicates that people who appear to be most at risk are either health care workers taking care of sick people or family members or household contacts of those who are infected with SARS. That pattern of transmission is what would typically be expected in a contagious respiratory or flu-like illness. There is no indication that SARS is linked to bio-terrorism.

This information has been compiled from materials provided by several federal agencies. For additional information or resource documentation, please reference the websites that follow.

The World Health Organization
http://www.who.int/csr/sars/en/

Centers for Disease Control and Prevention
http://www.cdc.gov/ncidod/sars/index.htm

Find your state health department:
http://www.cdc.gov/other.htm#states

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