MINNESOTA
DEPARTMENT
OF HEALTH
D ISEASE C ONTROL N EWSLETTER
Volume 31, Number 6 (pages 57-68)
September/October 2003
SARS: Severe Acute Respiratory Syndrome
History
Severe Acute Respiratory Syndrome
(SARS) emerged in Guangdong
Province, China in November 2002.
On February 11, 2003, Chinese
officials notified the World Health
Organization (WHO) of an outbreak of
acute respiratory syndrome that had
affected 305 persons and caused five
deaths.
In late February 2003, the disease
traveled out of Guangdong Province
via a physician who had treated
patients there suffering from pneumo­
nia. The physician subsequently
stayed at “Hotel M” in Hong Kong, at
which time he had been ill with
respiratory symptoms for over 1 week.
Epidemiologic investigations by Hong
Kong authorities, the Centers for
Disease Control and Prevention
(CDC), and WHO demonstrated that
transmission occurred from this
physician to four health care workers
(HCWs) who cared for him, two family
members, and 10 hotel guests. The
disease subsequently spread to 29
countries and caused outbreaks in
Toronto, Singapore, Taiwan, and
Hanoi, where secondary transmission
to close contacts (including HCWs)
occurred.
Etiology
SARS was identified in Hanoi by WHO
epidemiologist Dr. Carlo Urbani in
February 2003; he described a
transmissible severe pneumonia of
unknown cause. Dr. Urbani died of
SARS on March 29, 2003. By midApril, scientists in Germany, Hong
Kong, and at CDC had identified a
novel coronavirus (SARS-CoV) in
specimens from SARS-affected
individuals. SARS-CoV was isolated in
Vero E6 tissue culture cell lines.
Examination by electron microscopy
identified the virus as a member of the
family Coronaviridae, and sequencing
characterized it as a unique new virus.
Serologic assays were developed
using indirect fluorescent antibody
(IFA) and enzyme-linked
immunosorbent assay (ELISA)
techniques.
Origins of SARS-CoV
Coronaviruses have been found in a
broad range of animals, ranging from
snakes and birds to mammals. SARSlike viruses have been found in palm
civets, raccoon dogs, and ferret
badgers. Palm civets are considered a
culinary delicacy in southern China. It
is speculated that the virus passed
from animals to humans through
butchering, close contact, or eating
undercooked meat. It is not clear
whether these animals are the natural
reservoir of the virus.
WHO/CDC Case Definition
On March 15, 2003, WHO issued an
initial surveillance case definition for
SARS, with clinical and epidemiologic
criteria. The United States case
definition was revised by the Council of
State and Territorial Epidemiologists in
June 2003 and became effective July
1, 2003. The updated case definition
includes clinical, epidemiologic,
laboratory, and exclusionary criteria, as
well as case classifications for prob­
able and suspect cases (Table 1).
Spread of SARS
On September 26, 2003, WHO
reported a global total of 8,098 SARS
cases, including 774 (10%) deaths and
1,707 (21%) cases in HCWs.
Among 251 cases in Canada, there
were 43 (17%) deaths and 109
(43%) cases (including three
deaths) among HCWs.
On July 29, 2003, CDC reported 159
suspect and 33 probable SARS cases
from 36 U.S. states and Puerto Rico.
No deaths were reported. Only eight
probable case-patients had laboratory
evidence of SARS-CoV, of whom four
had traveled to Hong Kong (one also
had traveled to Guangdong), two had
traveled to Toronto, and one to
Singapore. One of the laboratoryconfirmed probable cases was a
household contact of another case.
Convalescent serum specimens have
not been obtained from the other 25
probable cases or any of the 159
suspect cases; therefore, it is unknown
whether these persons truly had
SARS.
In Minnesota, 11 SARS cases (three
probable and eight suspect) were
continued....
Inside:
Infection Control Recommendations for SARS ............................ 60
Minnesota Influenza Vaccination
Plan, 2003-04 .............................. 63
A Statewide Retrospective Survey
of Immunization Rates in Children
Entering Kindergarten
in 2001-02 .................................... 64
MDH Adopts New School and
Child Care Immunization
Requirements ............................. 66
9th Annual Emerging Infections in
Clinical Practice and Emerging
Health Threats Conference ....... 67
reported according to the initial case
definition. The case-patients ranged in
age from 8 months to 71 years; all had
a history of travel to SARS-affected
areas with known community transmis­
sion. Two of the probable cases, both
children, were hospitalized. No cases
required assisted ventilation, and all
recovered. As of July 15, two probable
and seven suspect cases were
excluded due to negative convalescent
SARS-CoV serology. One probable
case was excluded based on an
alternate diagnosis, and one suspect
case did not have a convalescent
specimen drawn.
Efforts to Contain the Spread of
SARS
In March 2003, WHO and CDC issued
travel alerts and advisories for persons
who planned to travel to areas where
there was known community transmis­
sion of SARS. Screening measures
were recommended for passengers
departing from airports in areas with
local transmission. In some places,
instruction cards were distributed to air
and train passengers arriving from
SARS-affected areas. The cards
informed passengers about the signs
and symptoms of SARS. Isolation of
SARS cases and quarantine of
contacts were implemented in Hong
Kong, Taiwan, Toronto, and Singapore.
In some areas, hospitals were closed
to new admissions and schools were
closed.
The last documented case in the
global SARS outbreak occurred on
June 15, 2003, in Taiwan. An isolated
case in a laboratory worker with
occupational exposure was reported
on September 9, 2003, in Singapore.
Clinical Presentation and
Transmission
SARS typically has an incubation
period of 2 to 10 days; in rare cases,
the incubation has been longer. A
prodrome consisting of fever greater
than 100.4°F (38°C), chills, and rigors
usually occurs. Other symptoms may
include headache, myalgia, sore
throat, malaise, anorexia, dizziness,
and diarrhea. Some persons also may
have a mild respiratory illness.
Typically, neurologic or dermatologic
manifestations are absent. After 3 to 7
days, a second phase of the disease
begins with involvement of the lower
respiratory tract. Initially, there is a dry
non-productive cough or dyspnea,
which may progress to pneumonia and
hypoxia. Chest radiographs may be
normal during the febrile prodrome.
However, in a substantial proportion of
patients, the respiratory phase is
characterized by early focal interstitial
infiltrates progressing to more generalized, patchy, interstitial infiltrates.
Some chest radiographs have shown
areas of consolidation. In some cases
in which a chest radiograph was
normal, a high resolution CT scan
revealed infiltrates. Almost all confirmed SARS cases had abnormal
continued....
Table 1. United States Case Definition and Defining Criteria
for Severe Acute Respiratory Syndrome (SARS)
Clinical Criteria
• Asymptomatic or mild respiratory illness
• Moderate respiratory illness
temperature of >100.4°F (>38°C), and
one or more clinical findings of respiratory illness (e.g., cough, shortness
of breath, difficulty breathing, or hypoxia)
• Severe respiratory illness
temperature of >100.4°F (>38°C), and
one or more clinical findings of respiratory illness (e.g., cough, shortness
of breath, difficulty breathing, or hypoxia), and
♦ radiographic evidence of pneumonia, or
♦ respiratory distress syndrome, or
♦ autopsy findings consistent with pneumonia or respiratory distress
syndrome without an identifiable cause
Epidemiologic Criteria
• Travel (including transit in an airport) within 10 days of onset of symptoms
to an area with current, previously documented, or suspected community
transmission of SARS, or
• Close contact within 10 days of onset of symptoms with a person known or
suspected to have SARS
Laboratory Criteria
• Confirmed
detection of antibody to SARS-associated coronavirus (SARS-CoV) in a
serum sample, or
detection of SARS-CoV RNA by RT-PCR, confirmed by a second PCR
assay using a second aliquot of the specimen and a different set of
PCR primers, or
isolation of SARS-CoV
• Negative
absence of antibody to SARS-CoV in a convalescent serum
sample obtained >28 days after symptom onset
• Undetermined
laboratory testing not performed or incomplete
Case Classification
• Probable case: meets the clinical criteria for severe respiratory illness of
unknown etiology and epidemiologic criteria for exposure; laboratory criteria
confirmed or undetermined
• Suspect case: meets the clinical criteria for moderate respiratory illness of
unknown etiology and epidemiologic criteria for exposure; laboratory criteria
confirmed or undetermined
Exclusion Criteria
• A person may be excluded as a suspect or probable case if:
an alternative diagnosis can fully explain the illness, or
the case has a convalescent serum sample (i.e., obtained >28
days after symptom onset) that is negative for antibody to SARS-CoV, or
the case was reported on the basis of contact with an index case that was
subsequently excluded as a case of SARS, provided other epidemiologic
exposure criteria are not present
58
chest radiographs by 7 days after
onset of symptoms. Early in the
course of disease, the absolute
lymphocyte count often is decreased.
At the peak of the respiratory illness,
approximately half of patients have
leukopenia and thrombocytopenia or
low-normal platelet counts (50,000150,000/µL). Early in the respiratory
phase, elevated CPK levels (as high
as 3,000 IU/L) and hepatic transami­
nases (two to six times the upper limits
of normal) have been noted. Renal
function has remained normal in most
patients.
SARS-affected individuals and during
aerosol-generating procedures in
which scrupulous infection control
procedures were not followed. Clini­
cians evaluating suspected SARS
cases should use Standard (e.g., hand
hygiene), Airborne (e.g., N95 respira­
tor), and Contact (e.g., gowns and
gloves) Precautions and eye protec­
tion. Clinicians are urged to develop
an infection control protocol for
outpatient and inpatient care, including
education of staff. (See the next article
for further information on infection
control recommendations.)
SARS appears to be spread via close
person-to-person contact with symp­
tomatic individuals, primarily through
contact with infectious materials and
droplets. Airborne transmission cannot
be ruled out. Aerosol-generating
procedures, such as nebulizer treat­
ments, bronchoscopy, intubation,
airway suctioning, diagnostic sputum
induction, positive pressure ventilation
via facemask, and high-frequency
oscillatory ventilation are considered
procedures associated with a high risk
for transmission. Most transmission of
SARS to HCWs appears to have
occurred after close contact with
Tests Available
CDC recommends that initial testing
for a patient with suspected SARS
should include chest radiograph, pulse
oximetry, blood cultures, sputum for
Gram stain and culture, and rapid
testing for viral respiratory pathogens,
particularly influenza A and B and
respiratory syncytial virus. Collection
of a specimen for Legionella and
pneumococcal urinary antigen testing
also should be considered. Clinicians
should save any available clinical
specimens (e.g., respiratory fluids,
blood, and serum) for additional testing
until a final diagnosis is made. In
Figure 1. Recommended Specimens to be Collected for Evaluation of
Potential Cases of Severe Acute Respiratory Syndrome (SARS)*
Outpatient
Inpatient
Fatal
Upper Respiratory
1. Nasopharyngeal
and oropharyngeal
swabs
2. Nasopharyngeal
aspirate (for
children < 2 years
of age)
Blood
1. Acute and convalescent
(>28 days) serum
2. Whole blood
Upper Respiratory
1. Nasopharyngeal and
oropharyngeal swabs
2. Nasopharyngeal
aspirate
Tissue
1. Fixed tissue from all
major organs (e.g., lung,
heart, spleen, liver, brain,
kidney, adrenals)
2. Frozen tissue from lung
and upper airway (e.g.,
trachea, bronchus)
Stool
Lower Respiratory
Broncheoalveolar lavage,
tracheal aspirate, or pleural
tap
Blood
1. Acute and convalescent
(>28 days) serum
2. Whole blood
Stool
Upper Respiratory
1. Nasopharyngeal aspirate
2. Nasopharyngeal and
oropharyngeal swabs
Lower Respiratory
Broncheoalveolar lavage,
tracheal aspirate, or pleural
tap
Blood
1. Serum
2. Whole blood
*Adapted from information provided by the Centers for
Disease Control and Prevention
Stool
59
patients in which there is a high index
of suspicion of SARS, viral cell culture
should not be attempted because
SARS-CoV can grow on tissue culture
lines commonly used by hospital
laboratories and pose a threat to the
health and safety of the laboratory
workers. Recommended specimens
for SARS testing are listed in Figure 1.
The Minnesota Department of Health
(MDH) Public Health Laboratory can
perform viral isolation, polymerase
chain reaction (PCR), and serologic
assays for SARS-CoV. Because of the
investigative nature of these tests,
appropriate safeguards must be in
place. Before submitting a specimen
to the MDH Laboratory for testing,
clinicians should consult MDH and
obtain informed consent from the
patient.
To report a suspect SARS case, or if
you have questions, call 612-676-5414
or 1-877-676-5414.
Possible Re-emergence of SARS
It is possible that SARS will return.
Three reasons suggest this possibility.
First, the animals implicated as
possible virus reservoirs are again
available for purchase and consump­
tion. Second, we do not completely
know the natural history of SARS. It is
possible that asymptomatic carriage
may occur. Third, other coronaviruses
related to SARS-CoV have shown a
predilection for fall and winter months.
Because of this possibility, clinicians
are urged to remain alert for SARS.
MDH is developing a plan to conduct
surveillance for HCWs who are
hospitalized with a diagnosis of
pneumonia. Since HCWs have been
identified as a group at higher risk for
SARS, this type of surveillance could
facilitate rapid identification of clusters
of illness that may be due to SARS.
Additional information on SARS is
available at www.cdc.gov/ncidod/sars/
and www.who.int/csr/sars/en/.
Infection Control Recommendations for SARS
Background
SARS is transmitted through contact
with or inhalation of infected droplets
and may be transmitted via the
airborne route or through contact with
contaminated fomites. Airborne
transmission occurs by dissemination
of either droplet nuclei or dust particles
that contain the infectious agent.
Airborne droplet nuclei are small
particle residues (<5 µm) of evapo­
rated droplets that contain microorgan­
isms and can remain suspended in the
air for long periods of time. Microor­
ganisms carried in this manner can be
dispersed widely by air currents and
may be inhaled by an individual who is
in the same room as the source patient
or who is further away from the source
patient, depending on environmental
factors.
Critically ill individuals may be at
higher risk of transmitting SARS.
Aerosol-generating procedures also
may increase the risk of transmission
to health care workers (HCWs).
Aerosol-generating procedures are
those capable of stimulating cough and
promoting aerosol generation, such as
aerosolized medication treatment
(nebulizers); diagnostic sputum
induction; bronchoscopy; airway
suctioning; endotracheal intubation;
positive pressure ventilation via
facemask (e.g., BiPAP, CPAP), during
which air may be forced out around the
facemask; and high-frequency oscilla­
tory ventilation (HFOV). These
procedures should be performed only
when medically necessary, and only
essential personnel wearing appropri­
ate personal protective equipment
(PPE) should be present. It may be
helpful to sedate patients for proce­
dures such as bronchoscopy or
intubation in order to minimize cough­
ing. Infection control guidelines for
aerosol-generating procedures are
described later in this article.
Inpatient Infection Control
Infection control personnel should be
notified immediately when a suspect
SARS patient is admitted to the
hospital. Infection control measures
should include Standard, Contact and
Airborne Precautions. In addition to
routine Standard Precautions (e.g.,
hand hygiene), HCWs should wear eye
protection (sealed goggles or face
shield) for all patient contact. Contact
Precautions involve the use of gown
and gloves for contact with the patient
or the patient’s physical environment.
Airborne Precautions require a
negative pressure isolation room with
at least 6 to 12 air changes per hour
and use of an N95 filtering disposable
respirator for persons entering the
room.
If a negative pressure isolation room is
not available, the patient should be
placed in a private room, and all
persons entering the room should wear
N95 respirators. A qualitative fit-test
should be conducted for N95 respira­
tors; detailed information on fit-testing
is available at www.osha.gov/SLTC/
etools/respiratory/oshafiles/
fittesting1.html. Once worn in the
presence of a SARS patient, a respira­
tor should be considered potentially
contaminated, and touching the
outside of the device should be
avoided. Upon leaving the patient’s
room, disposable respirators should be
removed and discarded as infectious
waste, followed by proper hand
hygiene. If N95 respirators are not
available, HCWs should wear tightfitting surgical masks.
In addition to respiratory protection,
HCWs must be careful to contain the
area of contamination. HCWs should
avoid touching their faces or PPE with
contaminated gloves. They should
avoid contaminating surfaces around
the patient or the patient’s room and
use care when removing their PPE, in
order to avoid contaminating skin,
clothing, or mucous membranes.
Standard procedures for removing PPE
in a manner that minimizes the
potential for self-contamination should
be developed, and HCWs should be
trained in these procedures. Proper
hand hygiene should be performed
after removing PPE and leaving the
patient’s room.
Hospitals should screen visitors for
symptoms of SARS. If contacts of
SARS cases exhibit fever or respira­
tory symptoms, they should not be
allowed to enter the health care facility
as visitors, but be evaluated as
suspect cases. Passive surveillance
for SARS-like illness should be
conducted for all HCWs in a facility
where a SARS patient is receiving
care, and active surveillance for fever
60
and respiratory symptoms should be
conducted for HCWs for 10 days
following unprotected exposure to
SARS. If the exposure was not highrisk and fever and respiratory symp­
toms are not present, the HCW does
not need to be excluded from work.
However, HCWs who develop such
symptoms should not report for duty;
they should stay at home and report
symptoms to the facility’s appropriate
contact person immediately. Following
an unprotected high-risk exposure
(e.g., aerosol-generating procedure),
HCWs should be excluded from duty
for 10 days, even if fever or respiratory
symptoms are not present.
Outpatient Infection Control
If SARS re-emerges, persons seeking
medical care for acute respiratory
infections should be asked about
possible exposure to someone with
SARS or recent travel to an affected
area. If SARS is suspected, a surgical
mask should be provided and placed
over the patient’s nose and mouth. If
masking the patient is not feasible, the
patient should be asked to cover his or
her mouth with a disposable tissue
when coughing, sneezing, or talking.
The patient should be separated from
others in the reception area as soon as
possible, preferably in a private room
with negative pressure relative to the
surrounding area and with the door
closed. If a negative pressure room is
not available, the patient should be
evaluated in a private room. Family
members or other contacts accompa­
nying the patient also may require
isolation and should be asked about
symptoms as well. Postpone initiation
of cleaning the room to allow time for
the ventilation system to remove any
residual airborne viral particles. The
room should be cleaned and disin­
fected using PPE prior to another
patient being seen in the room. For
further information see www.cdc.gov/
ncidod/sars/cleaningpatientenviro.htm.
All HCWs should wear N95 respirators
and eye protection while caring for
patients with suspected SARS. In
addition, HCWs should follow Standard
and Contact Precautions.
Aerosol-Generating Procedures
Any medically necessary aerosolgenerating procedure should be
continued....
performed in a negative pressure
isolation room. If this is not available,
the procedure should be performed in
a private room away from other
patients. If possible, steps should be
taken to increase air changes, to
create negative pressure relative to the
adjacent room or hallway, and to avoid
recirculation of the room air. If
recirculation of air from such rooms is
unavoidable, the air should be passed
through a HEPA filter before recircula­
tion. Air-cleaning devices, such as
portable HEPA filtration units, may be
used to further reduce the concentra­
tion of contaminants. Doors should be
kept closed, except when entering or
leaving the room, and entry and exit
should be minimized. Some hospitals
caring for SARS patients have used
bacterial/viral filters on exhalation
valves of mechanical ventilators to
prevent contaminated aerosols from
entering the environment. Although
the effectiveness of this measure in
reducing the risk of transmission of
SARS is unknown, the use of such
filters may be prudent during HFOV of
SARS patients.
The optimal combination of PPE to
prevent transmission of SARS during
aerosol-generating procedures is
unknown. PPE must cover the arms
and torso and fully protect the eyes,
nose, and mouth; additional PPE to
protect all exposed skin should be
considered. A single isolation gown
should be used. A disposable full-body
isolation suit may be considered; some
suits have an attached hood to cover
the hair. Another alternative is a
disposable surgical hood with an
attached face shield, in combination
with a disposable respirator. It is
unknown whether covering exposed
skin or hair on the head or neck further
reduces the risk of transmission. A
single pair of disposable gloves that fit
snugly over the wrist should be used,
and goggles should fit snugly around
the eyes. A face shield may be worn
over goggles to protect exposed areas
of the face but should not be used as a
primary form of eye protection for
these procedures.
Respiratory protection for aerosolgenerating procedures must ensure
that HCWs are protected from expo­
sure to aerosolized infectious droplets
through breaches in respirator seal
integrity. Disposable particulate
respirators (e.g., N95, N99, or N100)
are the minimum acceptable level of
respiratory protection. HCWs must be
fit-tested to the specific respirator
model that they will wear and know
how to check their facepiece seals. If
disposable respirators cannot be fittested to the individual, a higher level
of respiratory protection should be
used. Some facilities have used
higher levels of respiratory protection
for persons present during aerosolgenerating procedures on SARS
patients. These measures include
powered air purifying respirators
(PAPRs) designed with loose-fitting
facepieces that form a partial seal with
the face, PAPRs with hoods that
completely cover the head and neck
and that also may cover portions of the
shoulder and torso, PAPRs with tightfitting facepieces (both half and full
facepiece), and full facepiece elasto­
meric negative pressure (i.e., nonpowered) respirators with N, R, or
P100 filters. At this time, there is not
sufficient information to determine
whether these higher levels of respira­
tory protection will further reduce the
risk of transmission. Factors that
should be considered in choosing
respirators include availability, impact
on mobility, the potential for exposure
to higher levels of aerosolized respira­
tory secretions, and the potential that
reusable respirators may serve as
fomites.
Decontaminating, Cleaning, and
Disinfecting PPE and Environmental
Surfaces
Disposable gloves and PPE should be
used when cleaning. Horizontal
surfaces should be cleaned and
disinfected as soon as possible
following an aerosol-generating
procedure. Disinfectants should be
used to decontaminate reusable PPE
according to the manufacturer’s
guidelines.
Infection Control in the Home or
Residential Setting
SARS patients should stay isolated at
home until 10 days after the resolution
of fever, provided that respiratory
symptoms are absent or improving.
During this time, the following infection
control precautions should be used:
1. All members of the household
should carefully implement proper
hand hygiene (e.g., frequent hand
washing or use of alcohol-based
hand rubs), particularly after
contact with body fluids.
61
2. Disposable gloves should be
considered for any direct contact
with body fluids of a SARS patient.
Immediately after activities involv­
ing contact with body fluids, gloves
should be removed and discarded
and hands should be cleaned.
Gloves must never be washed or
reused.
3. Each SARS patient should be
advised to cover his or her mouth
and nose with a facial tissue when
coughing or sneezing. If possible,
the patient should wear a surgical
mask during close contact (i.e., in
the same room) with uninfected
persons. If the patient is unable to
wear a surgical mask, household
members should wear N95 respira­
tors (or surgical masks, if N95
respirators are not available)
when in close contact with the
patient.
4. If possible, SARS patients should
not share a bathroom with other
household members. If sharing a
bathroom is necessary, bathrooms
should be cleaned frequently with a
household disinfectant according to
the manufacturer’s instructions;
gloves should be worn during this
activity.
5. Sharing of eating utensils, towels,
and bedding between SARS
patients and others should be
avoided, although such items may
be used by others after routine
cleaning (e.g., washing with soap
and hot water). Environmental
surfaces soiled by body fluids
should be cleaned with a house­
hold disinfectant according to the
manufacturer’s instructions; gloves
should be worn during this activity.
6. Household waste soiled with body
fluids of SARS patients, including
facial tissues and surgical masks,
may be discarded as normal waste.
7. Household members and other
close contacts of SARS patients
should be vigilant for fever (i.e.,
measure temperature twice daily)
or respiratory symptoms; if
these develop, medical evaluation
should be sought immediately
(Figure 1). Prior to evaluation,
HCWs should be informed that
the individual is a close contact of
a SARS patient so that arrange­
continued...
Figure 1. Management of Persons Who Have Been Exposed to SARS1
Exposed Person
Develops fever AND respiratory
symptoms within 10 days
(i.e., meets case definition)
Develops fever OR respiratory
symptoms within 10 days
(i.e., does not meet case definition)
Does not develop fever or
respiratory symptoms within 10
days
Use isolation precautions2 for 72 hours
Does not progress to
meet case definition but has
persistent fever or unresolving
respiratory symptoms
Progresses to
meet case
definition
Use isolation precautions2 until 10
days after resolution of fever,
provided respiratory symptoms
are improving or absent
Symptoms improve
or resolve
Continue isolation precautions for
an additional 72 hours, then
perform clinical evaluation
Does not progress to
meet case definition3
Discontinue
isolation
precautions4
Isolation
precautions not
recommended4
1. Exposure includes travel from areas with documented or suspected community transmission of SARS or close contact with persons who
have SARS. Close contact is defined as having cared for or lived with a person known to have SARS or having a high likelihood of
direct contact with respiratory secretions and/or body fluids of a patient known to have SARS. Examples of close contact include
kissing or embracing, sharing eating or drinking utensils, close conversation (<3 feet apart), physical examination, and any other direct
physical contact between persons. 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.
2. Isolation precautions include limiting the patient’s interactions with others outside the home (e.g., should not go to work, school, out-ofhome day care, church, or other public areas) and following infection control guidelines for the home or residential setting, if not
admitted to hospital for care.
3. Discontinuation of isolation precautions for patients who have not met the case definition 6 days following onset of symptoms but who
have persistent fever or respiratory symptoms should be done only after consultation with local public health authorities and the
evaluating clinician. Factors that might be considered include the nature of the potential exposure to SARS, the nature of contact with
others in residential or work settings, and evidence for an alternative.
4. Persons need not limit interactions outside the home (e.g., need not be excluded from work, school, out-of-home day care, church, or
Source: Centers for Disease Control and Prevention
other public areas).
ments can be made to prevent
transmission. Household members
or other close contacts with
symptoms of SARS should follow
the same precautions recom­
mended for SARS patients.
8. In the absence of fever or respira­
tory symptoms, household
members or other close contacts of
SARS patients need not limit their
activities outside the home.
Surgical Masks vs. N95 Respirators
The purpose of a surgical mask is to
filter or redirect particles expelled by
the wearer. Surgical masks are not
designed for use as respirators. Most
surgical masks do not effectively filter
small particles from the air and do not
prevent leakage around the edge of
the mask when the user inhales. The
purpose of a respirator is to protect the
wearer from airborne particles gener­
ated by nearby sources. Respirators
are certified by the National Institute
for Occupational Safety and Health,
and certification tests evaluate the
performance of filters by measuring
their collection efficiency. Performance
of surgical masks and respirators is
dependent on the efficiency of the filter
(i.e., how well the filter collects
airborne particles) and the fit (i.e., the
degree of leakage between the
facepiece and the face).
62
Federal Occupational Safety and
Health Administration (OSHA) regula­
tions require a respiratory protection
program when employees are required
to wear respirators. Because not
everyone can tolerate a respirator,
employees must be medically evalu­
ated prior to fit-testing. If the em­
ployee passes the medical evaluation,
a qualitative fit-test (which involves the
wearer’s reaction to the smell or taste
of an airborne challenge such as
irritant smoke or Bitrex) should be
conducted prior to use of an N95
respirator. Employees must have a
choice of respirator sizes and be
trained in how to wear, fit-check, store,
and maintain respirators. Persons with
continued on page 68.....
Minnesota Influenza Vaccination Plan, 2003-04
The Minnesota Influenza Vaccination
Plan is issued by the Minnesota
Department of Health (MDH) and
endorsed by the Minnesota Coalition
on Adult Immunization and the MDH
Immunization Practices Task Force.
The plan establishes a timeline and
strategy for the organization of
influenza vaccination programs for the
2003-04 influenza season. The plan is
summarized in Tables 1 and 2. If
indications of a possible vaccine
shortage or a delay in availability of
vaccine arise, MDH may modify the
plan to ensure capacity for vaccination
of the highest priority populations.
MDH will post updates on this plan at
http://www.health.state.mn.us/immunize.
The Influenza Vaccination Plan is
directed to all facilities that directly
or indirectly provide influenza
vaccination services in Minnesota,
including traditional sites (e.g.,
medical clinics, hospitals, home care
agencies, local public health
agencies, long-term care facilities,
and occupational health programs)
as well as nontraditional sites (e.g.,
pharmacies; retail stores, including
food and drug stores; vaccination
vendors; worksites; senior centers,
and community centers).
Successful implementation of this
plan requires the collaboration of
health care providers and public
health professionals statewide.
Table 1. Timeline, Activities, and Targeted Groups for Influenza Vaccination, 2003-04
Activity and Targeted Group
Timeline
October (or earlier, if vaccine is
available) through March (or until the
end of influenza season)
• Vaccinate persons at highest risk for serious influenza-related
complications and persons likely to transmit influenza to high-risk persons
(Priority Category 1 in Table 2).
• Vaccinate persons in Priority Category 2 (Table 2) when the supply of
vaccine is adequate.
November through March (or until the
end of influenza season)
• Continue vaccinating persons in Priority Category 1 (Table 2).
• Vaccinate persons in Priority Category 2 (Table 2).
No one seeking influenza vaccine should be turned away!
Table 2. Priority Categories for Influenza Vaccination
Priority Category 1
Persons
•
•
•
at highest risk for serious influenza-related complications include:
persons 65 years of age or older;
residents of nursing homes or other chronic care facilities;
adults and children who have diabetes, heart disease, asthma, or other chronic
pulmonary or cardiovascular disorders;*
• adults and children who required regular medical follow-up or hospitalization due to
chronic disease(s) during the preceding year;
• children (6 months to18 years of age) who are receiving long-term aspirin therapy;*
• women who will be in the second or third trimester of pregnancy during the influenza
season; and
• children 6 to 23 months of age, when feasible.*
*Children who are less than 9 years of age and receiving vaccine for the first time
need a booster dose 1 month after the initial dose.
Persons likely to be at high risk include:
• persons 50 to 64 years of age.
Priority
Category 2
Persons likely to transmit influenza to those at high risk include:
• physicians, nurses, and other staff in hospital or outpatient settings;
• employees of nursing homes or chronic care facilities who have contact with
patients or residents;
• employees of assisted living facilities or other residential facilities for persons in highrisk groups;
• providers of home care to high-risk persons (e.g., visiting nurses);
• household contacts of high-risk persons; and
• household contacts of children 0 to 23 months of age, when feasible.
Healthy persons 2 years of age or older who wish to reduce their likelihood of becoming ill with influenza, including:
• persons in institutional settings (e.g., college students, incarcerated persons);
• employees of health care facilities who do not provide direct patient care;
• persons who provide essential community services; and
• healthy persons in the workplace.
63
A Statewide Retrospective Survey of Immunization Rates in
Children Entering Kindergarten in 2001-02
Introduction
Assessment of immunization levels is
critical in directing public health policy
in the area of vaccine delivery. During
1992, the Minnesota Department of
Health (MDH), with support from the
Centers for Disease Control and
Prevention (CDC), initiated the
Minnesota Immunization Action Plan
(IAP) to improve immunization levels
among preschoolers in the state. As
part of the IAP, MDH conducted a
statewide assessment of immunization
rates among children entering kinder­
garten in 1992-93. This survey was
repeated in 1996-97 and again for
children who entered kindergarten
during the 2001-02 school year. This
report presents data from the 2001-02
survey and compares them with data
from the prior surveys.
Methods
Dates of vaccination against diphthe­
ria, tetanus, pertussis, polio, measles,
mumps, and rubella were collected
retrospectively from school immuniza­
tion records for all students. In the
2001-02 survey, hepatitis B vaccination
dates also were collected, as this
vaccine was required for school entry
beginning in the fall of 2000. Immuni­
zation levels were assessed for each
month of a child’s life from 2 to 48
months of age. Additional information
on exemptions to immunization, race/
ethnicity, and geographic area of
residence also was collected. Exemp­
tions were defined as conscientious
opposition to immunization, medical
contraindication to vaccination, or
previous history of disease. Area of
residence was defined by the neigh­
borhood school attended or the ZIP
Code of residence in metropolitan
locations where open enrollment
allowed children to attend schools
outside their neighborhoods of
residence.
A comprehensive list of schools was
obtained from the Minnesota Depart­
ment of Education. Some school
districts maintain immunization records
in computerized databases, which
were submitted directly to MDH. When
computerized data were not available,
local public health nurses or school
nurses abstracted immunization
records.
The recommended vaccination series
was defined according to the guide­
lines of the Advisory Committee on
Immunization Practices and the
American Academy of Pediatrics. The
recommended series of vaccines
included vaccines for diphtheria,
tetanus, and acellular pertussis (DTaP)
at 2, 4, 6, and 18 months; polio (IPV)
at 2, 4, and 18 months; measles,
mumps, and rubella (MMR) at 15
months, and hepatitis B (hepB) at birth
to 1 month, 2, and 6 months of age.
Other vaccinations (i.e., Haemophilus
influenzae type b [HiB], varicella, and
pneumococcal conjugate [PCV-7])were
not required for school entry at the
time of the surveys and thus were not
included in the assessment.
The age-appropriate immunization
level was assessed at each month of
age. Age-appropriate immunization
was defined as having received all
vaccines in the series within 2 months
after the recommended age. Goal
points of 4, 6, 8, 17, and 20 months
were established to correspond to the
recommended dates for the primary
immunization series, allowing a 2­
month grace period to receive the
vaccines. Therefore, age-appropriate
immunization at 4 months of age (Goal
Point 1) included receiving DTaP1 and
Polio1; age-appropriate at 6 months
(Goal Point 2) included receiving
DTaP2 and Polio2; age-appropriate at
8 months (Goal Point 3) included
receiving DTaP3 and Polio2; ageappropriate at 17 months (Goal Point
4) included receiving DTaP3, Polio2,
and MMR1; and age-appropriate at 20
months (Goal Point 5) included
receiving DTaP4, Polio3, and MMR1.
HepB immunization rates were
assessed separately.
Results
During the 2001-02 school year,
65,653 children were enrolled in 1,200
public and private kindergarten
programs. In 1992-93 and 1996-97,
69,115 and 69,772 children were
enrolled in kindergarten, respectively.
For all three surveys, information was
obtained on all enrolled children. A
comparison of immunization rates by
the five age-specific goal points is
shown in Table 1. Statewide immuni­
zation rates improved by 3-20% for all
goal points from 1996-97 to 2001-02.
Figure 1 presents statewide progress
toward Minnesota’s goal of having 90%
of children immunized.
Overall immunization levels in most
geographic areas improved in 2001­
02; only 17 county/city immunization
levels decreased at the fifth goal point
(20 months of age). However, as
observed in 1992-93 and 1996-97,
every region in Minnesota had pockets
of under-immunized children. For
example, in Olmsted County, 84% of
students were up-to-date with all
recommended immunizations at 24
months of age. Of 30 schools in
Olmsted County, however, one had
immunization levels of 63%, and four
had immunization levels of 71-74%.
Together, these five schools repre­
sented 21% of Olmsted County’s
kindergartners.
continued..........
Table 1. Comparison of Immunization Levels Between Retrospective
Immunization Surveys, 1992-93, 1996-97, and 2001-02
Age:
Immunizations Needed
4 months:
DTaP1, Polio1
6 months:
DTaP2, Polio2
8 months:
DTaP3, Polio2
17 months:
DTaP3, Polio2, MMR1
20 months:
DTaP4, Polio3, MMR1
64
Percent Up-to-Date by Year
1992-93
1996-97
2001-02
Percent Change,
1996-97 to 2001-02
86%
90%
93%
+3%
75%
80%
87%
+7%
64%
71%
81%
+10%
57%
65%
78%
+13%
46%
55%
75%
+20%
In 2001-02, 75% of students had
received the first dose of hepB by 2
months of age, 82% had received the
second dose by 6 months, and 84%
had completed the series by 20
months.
Race/ethnicity was identified for 92%
of students in the 2001-02 survey.
Among those with available informa­
tion, 80% were white, 2% were
American Indian/Alaskan Native, 5%
were Asian/Pacific Islander, 5% were
Hispanic, and 8% were black. White
students had higher average immuni­
zation levels than non-white students
at each goal point (Table 2). The
average difference between white and
non-white students across all goal
points was 19%, which represents a
lessening of racial disparities from
1996-97, when the average difference
was 27%.
The number and percentage of
children who were exempt from
immunizations in 2001-02 due to their
parents’ conscientiously held beliefs
more than doubled since the previous
survey. However, these children
remain a very small percentage of all
students. The number of children
exempt for conscientious reasons was
157 (0.2%) in 1992-93, 343 (0.5%) in
1996-97, and 837 (1.3%) in 2001-02.
These increases occurred while the
Figure 1. Comparison of Immunization Levels Between
Retrospective Kindergarten Surveys
100
90% Goal
90
Percent Immunized
80
70
60
50
1992-93 (n=69,115)
40
1996-97 (n=69,772)
2001-02 (n=65,653)
30
20
10
0
2
4
6
8
10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48
Age in Months
Table 2. Immunization Levels By Age and Race/Ethnicity, Retrospective
Kindergarten Survey, 2001-02
Percent Up-to-Date by Age
17 Months
6 Months
8 Months
total number of kindergarteners
surveyed remained virtually un­
changed.
Data from the 2001-02 survey were
analyzed to determine the extent of
missed opportunities for simultaneous
administration of DTaP4, Polio3, and
MMR1. Immunization dates for these
doses of the primary series were
compared to determine which were
given together and in what combina­
tion. Children with missed opportuni­
ties for simultaneous vaccination were
most likely to have received their
Polio3 and least likely to have received
DTaP4. Had these missed opportuni­
ties been eliminated, the percentage of
children who were age-appropriately
immunized by 20 months of age could
have been improved by 8% statewide.
Since 1996-97, the occurrence of
missed opportunities has declined by
10%.
Comment
School laws have helped to ensure
that most children are vaccinated by
their fifth birthday or upon enrolling in
school. However, delays in completing
the immunization series leave preschool-age children vulnerable to
disease.
Immunization registries are one means
to ensure that children begin their
immunizations on time and remain on
schedule. Currently, the Minnesota
Immunization Information Connection
(MIIC) is in use in 413 clinics and local
public health departments and in­
cludes immunization records for over
300,000 children. By early 2004, MIIC
will be in use in over 550 clinics and
local public health departments and
will include records for more than
1,000,000 children. Immunization
registries support efforts to assure
age-appropriate immunization in a
variety of ways, including reducing
missed opportunities, improving
documentation of immunizations,
reducing duplication of immunizations,
and assisting clinics with tracking and
recalling children who are behind
schedule.
Race/Ethnicity
4 Months
All students
93%
87%
81%
78%
75%
American Indian/
Alaskan Native
91%
80%
67%
71%
65%
Asian/Pacific
Islander
82%
69%
59%
65%
58%
Black
78%
68%
58%
61%
55%
Hispanic
87%
79%
70%
66%
58%
All non-white
83%
72%
62%
64%
57%
Public, private, and community-based
organizations must embrace the
common goal of ensuring that all
children in Minnesota have access to
and receive timely immunization
White
95%
91%
86%
81%
80%
continued....
65
20 Months
services. Specifically, continued
immunization efforts should focus on:
• enabling providers to use every
opportunity to provide needed
immunizations to children;
• strategically targeting pockets of
under-immunized children;
• continuing expansion and use of
immunization registries;
• ensuring that parents have access
to reliable sources of information
about vaccines; and
• working to eliminate immunization
disparities among racial/ethnic
groups.
Conclusion
The widespread use of immunizations
is considered one of the top 10 public
health accomplishments of the
twentieth century. Immunizing infants
and young children against vaccinepreventable diseases reduces illness,
prevents suffering, and saves lives of
children. Children are most vulnerable
to severe consequences of vaccinepreventable diseases from birth
through 5 years of age - i.e., before
they start school. Monitoring immuni­
zation levels of Minnesota’s youngest
citizens through population-based
surveys such as the Retrospective
Kindergarten Survey is a fundamental
responsibility of public health.
For more information on this survey,
contact the MDH Immunization,
Tuberculosis, and International Health
Section at 612-676-5414 or 1-877-6765414.
MDH Adopts New School and Child
Care Immunization Requirements
The Minnesota Department of Health
(MDH) has adopted new immunization
requirements, including several
modifications to current immunization
laws. Most of the modifications will
take effect October 4, 2003; however,
certain modifications will take effect
September 1, 2004. A summary of the
changes follows.
Effective October 2003
• Immunization Schedule: The
grace period in which school-age
children may complete their
primary immunization series is
shortened from 18 to 8 months, in
order to make it easier for school
nurses to bring children into
compliance during the school
year.
• Immunization Schedule: Vaccine
doses administered 4 or fewer
days before the minimum age
required in law are considered
valid and consistent with national
recommendations.
• Immunization Documentation:
All child care facilities and
elementary and secondary
schools are required to use MDH’s
official record form or a similar
document approved by MDH to
communicate immunization
requirements and exemption
procedures to parents/guardians.
The form requests information
about immunizations and includes
space for documenting medical or
conscientious exemptions.
• Hib Vaccine: One dose of the
Haemophilus influenzae type b
(Hib) vaccine must be given at 12
months of age or later in order to
be consistent with clinical guide­
lines.
• Hepatitis B Vaccine: Both the
three-dose hepatitis B vaccine
series and the alternate two-dose
series are valid for 11 to 15 yearolds.
• Suspension of Law: The Commis­
sioner of Health has authority to
suspend immunization law
requirements (121A.15 and
135A.14) to address a vaccine
shortage or emergency situation.
Effective September 2004
• Varicella (Chickenpox) Vaccine:
Documentation of varicella
vaccine or history of disease is
required for children 18 months to
5 years of age who are enrolled in
child care, as well as for schoolage children in kindergarten and
seventh grade. Documentation of
a history of varicella disease must
include one of the following:
signature of a health care
provider and the date of the
child’s varicella illness; or
signature of a health care
provider and a statement that
66
a parent’s or legal guardian’s
description of the disease
history is indicative of past
varicella infection; or
signature of a health care
provider or a representative of
a public clinic and laboratory
evidence of the child’s
varicella immunity; or
signature of the child’s parent
or legal guardian and the year
when the child had varicella
disease. (This item expires
on September 1, 2010.)
• Pneumococcal Vaccine:
Documentation of pneumococcal
conjugate vaccine is required for
children 2 to 24 months of age
who are enrolled in child care.
This vaccine protects against
meningitis, bloodstream infections,
and pneumonia.
• Measles, Mumps, Rubella Vac­
cine: Documentation of a second
dose of vaccine each for measles,
mumps, and rubella is required for
children entering kindergarten.
(Minnesota law requires the
second dose for children in grades
7 to 12 until the spring of 2012.)
For more information or a full copy of
the new requirements, contact the
MDH Immunization Program by calling
612-676-5414 or 1-877-676-5414, or
by sending an e-mail to
[email protected].
The new requirements also can be
found on the web at
www.health.state.mn.us/immunize.
9th Annual Emerging Infections in Clinical Practice and Emerging Health Threats Conference November 21, 2003 What Next? SARS, Monkey Pox, AIDS, Bioterrorism, and more....
Program Includes:
• SARS: Lessons Learned
and Predictions for the
Future - Frank A. Plummer
• Extraintestinal E.coli
Infections - James R.
Johnson • Emerging Disease in Animals and Their Impact on Human Health - Jeffrey Bender •
Immigrant Health Issues David Williams
•
AIDS in the Global Village
- W. Keith Henry
• Hot Topics from the
Minnesota Department of
Health - Richard Danila
•
Emerging Pathogens and
the Skin - Bruce J. Bart
•
Bioterrorism Preparedness
Update from the National
and State Perspectives Michael T. Osterholm,
Harry Hull, and Robert
Einweck
•
Food-borne Disease - Craig Hedberg Sponsored by the Minnesota Department of Health and the University of Minnesota, including the Division of
Infectious Diseases and International Medicine, Office of Continuing Medical Education, Medical School, Center for
Infectious Disease Research and Policy, and Academic Health Center
facial hair or facial anomalies that
interfere with the seal cannot wear an
N95 respirator. An alternative to an
N95 respirator is a PAPR, a mechani­
cal device in which a battery-powered
blower moves air through filters. If
PAPRs are used in the care of a SARS
patient, reusable elements should be
cleaned and disinfected after use and
used filters must be discarded safely.
There are no pediatric-sized respira­
tors.
Respirators should be fit-checked prior
to each wearing. To check the
respirator seal, the wearer should
place both hands completely over the
respirator and forcefully inhale and
exhale several times without disturbing
the position of the respirator. The
wearer should not feel any air leaking
between his or her face and the
respirator. If air leaks around the
nose, the nosepiece should be
readjusted. If air leaks at the respira­
tor edges, the straps along the sides of
the head should be readjusted. The
top strap should be high at the top
back of the head, and the bottom strap
should be around the neck and below
Dianne Mandernach, Commissioner of Health
Division of Infectious Disease Epidemiology, Prevention and Control
Harry F. Hull, M.D. ........................... Division Director & State Epidemiologist
Richard N. Danila, Ph.D., M.P.H. ............................... ADIC Section Manager
Kirk Smith, D.V.M., Ph.D. ...................................................................... Editor
Wendy Mills, M.P.H. .............................................................. Assistant Editor
Valerie Solovjovs ................................................................. Production Editor
the ears. If proper fit and seal cannot
be achieved, HCWs should not enter
the isolation room or treatment area.
Information presented here regarding
surgical masks and N95 respirators is
based on material provided by Lisa
Brosseau, Sc.D., University of Minne­
sota, and “Understanding Respiratory
Protection Against SARS” (http://
www.cdc.gov/niosh/npptl/respirators/
respsars.html). Additional information
on SARS and infection control is
available at
www.cdc.gov/ncidod/sars/ic.htm.
CHANGING YOUR ADDRESS?
Please correct the address
below and send it to:
DCN MAILING LIST
Minnesota Department of Health
717 Delaware Street SE
PO Box 9441
Minneapolis, MN 55440-9441
The Disease Control Newsletter is available on the MDH Acute Disease Investigation and Control
(ADIC) Section web site (http://www.health.state.mn.us/divs/dpc/ades/pub.htm).
The Disease Control Newsletter toll-free telephone number is 1-800-366-2597.
68