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Disease Control Measures Helped Contain Spread, But a Large-Scale 
Resurgence May Pose Challenges' which was released on July 30, 2003.

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Testimony:

Before the Permanent Subcommittee on Investigations, Committee on 
Governmental Affairs, U.S. Senate:

United States General Accounting Office:

GAO:

For Release on Delivery Expected at 9:00 a.m.

Wednesday, July 30, 2003:

SEVERE ACUTE RESPIRATORY SYNDROME:

Established Infectious Disease Control Measures Helped Contain Spread, 
But a Large-Scale Resurgence May Pose Challenges:

Statement of Marjorie E. Kanof:

Director, Health Care--Clinical and Military Health Care Issues:

GAO-03-1058T:

GAO Highlights:

Highlights of GAO-03-1058T, a report to the Permanent Subcommittee on 
Investigations, Committee on Governmental Affairs, U.S. Senate 

Why GAO Did This Study:

SARS is a highly contagious respiratory disease that infected more 
than 8,000 individuals in 29 countries principally throughout Asia, 
Europe, and North America and led to more than 800 deaths as of July 
11, 2003. Due to the speed and volume of international travel and 
trade, emerging infectious diseases such as SARS are difficult to 
contain within geographic borders, placing numerous countries and 
regions at risk with a single outbreak. While SARS did not infect 
large numbers of individuals in the United States, the possibility 
that it may reemerge raises concerns about the ability of public 
health officials and health care workers to prevent the spread of the 
disease in the United States.

GAO was asked to assist the Subcommittee in identifying ways in which 
the United States can prepare for the possibility of another SARS 
outbreak. Specifically, GAO was asked to determine 1) infectious 
disease control measures practiced within health care and community 
settings that helped contain the spread of SARS and 2) the initiatives 
and challenges in preparing for a possible SARS resurgence.

What GAO Found:

Infectious disease experts emphasized that no new infectious disease 
control measures were introduced to contain SARS in the United States. 
Instead, strict compliance with and additional vigilance to enforce 
the use of current measures was sufficient. These measures—case 
identification and contact tracing, transmission control, and exposure 
management—are well-established infectious disease control measures 
that proved effective in both health care and community settings. The 
combinations of measures that were used depended on either the 
prevalence of the disease in the community or the number of SARS 
patients served in a health care facility. For SARS, case 
identification within health care settings included screening 
individuals for fever, cough, and recent travel to a country with 
active cases of SARS. Contact tracing, the identification and tracking 
of individuals who had close contact with someone who was infected or 
suspected of being infected, was important for the identification and 
tracking of individuals at risk for SARS. Transmission control 
measures for SARS included contact precautions, especially hand 
washing after contact with someone who was ill, and protection against 
respiratory spread, including spread by large droplets and by smaller 
airborne particles. The use of isolation rooms with controlled airflow 
and the use of respiratory masks by health care workers were key 
elements of this approach. Exposure management practices—isolation and 
quarantine—occurred in both health care and home settings. Effective 
communication among health care professionals and the general public 
reinforced the need to adhere to infectious disease control measures.

While no one knows whether there will be a resurgence of SARS, 
federal, state, and local health care officials agree that it is 
necessary to prepare for the possibility. As part of these 
preparations, CDC, along with national associations representing state 
and local health officials, and others, is involved in developing both 
SARS-specific guidelines for using infectious disease control measures 
and contingency response plans. In addition, these associations have 
collaborated with CDC to develop a checklist of preparedness 
activities for state and local health officials. Such preparation 
efforts also improve the health care system’s capacity to respond to 
other infectious disease outbreaks, including those precipitated by 
bioterrorism. However, implementing these plans during a large-scale 
outbreak may prove difficult due to limitations in both hospital and 
workforce capacity that could result in overcrowding, as well as 
potential shortages in health care workers and medical equipment—
particularly respirators.

www.gao.gov/cgi-bin/getrpt?GAO-03-1058T.

To view the full product, including the scope and methodology, click 
on the link above. For more information, contact Marjorie E. Kanof at 
(202) 512-7101.

[End of section]

Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today as you consider effective infectious 
disease control measures to help contain the spread of Severe Acute 
Respiratory Syndrome (SARS) should future outbreaks occur. SARS is a 
highly contagious respiratory disease that infected more than 8,000 
individuals in 29 countries principally throughout Asia, Europe, and 
North America and led to more than 800 deaths as of July 11, 2003. Due 
to the speed and volume of international travel and trade, emerging 
infectious diseases such as SARS are difficult to contain within 
geographic borders, placing numerous countries and regions at risk with 
a single outbreak. SARS quickly became a worldwide health problem, 
prompting the World Health Organization (WHO) to issue a global alert 
for the first time in more than a decade--an alert that was cancelled 
on July 5, 2003. Although the outbreak is currently believed to be 
contained, the fact that SARS is a type of coronavirus--the source of 
some common colds--leads many to suggest that SARS could be seasonal 
and as such could recur in the fall and winter months.

Although all the modes of SARS transmission may not have been 
identified, the disease is most likely spread through person-to-person 
contact. Experts agree that infected individuals are contagious when 
symptomatic--a time during which they are more likely to seek medical 
attention and come into contact with health care workers. One unique 
characteristic of the SARS outbreak was the high rate of infection 
among health care workers, who--before the institution of specific 
protective measures--may have become infected while treating patients 
with SARS. The SARS outbreak in Asia demonstrated that the disease can 
also spread rapidly in the community, outside of hospital settings.

While SARS did not infect large numbers of individuals in the United 
States, the possibility that it may reemerge raises concerns about the 
ability of public health officials and health care workers to prevent 
the spread of the disease in the United States. To assist the 
Subcommittee in identifying ways in which the United States can prepare 
for the possibility of another SARS outbreak, my remarks today will 
focus on 1) infectious disease control measures practiced within health 
care and community settings that helped contain the spread of SARS and 
2) the initiatives and challenges in preparing for a possible SARS 
resurgence.

My testimony today is based on the review of documentation about 
infection control practices and guidelines, as well as descriptions 
about the origin of SARS and its spread. In addition, we spoke with 
leading national and international disease experts--most of whom were 
involved in either the investigation of SARS or in the treatment of 
patients with SARS. Specifically, we spoke with experts in infectious 
diseases, epidemiology, clinical medicine, and occupational safety from 
the Centers for Disease Control and Prevention (CDC) and WHO. We also 
spoke with public health officials of Health Canada and Toronto Public 
Health because Canada had the highest prevalence of SARS cases in North 
America. We interviewed state and local public health officials in 
California and New York--both of which had the greatest number of SARS 
cases reported in the United States. These officials represented the 
California Department of Health Services, the New York State Department 
of Health, and the New York City Department of Health and Mental 
Hygiene. We also spoke with hospital infectious disease experts in each 
of these states. In addition, we spoke with national infectious disease 
experts, hospital epidemiologists, and representatives from the 
National Association of County and City Health Officials (NACCHO) and 
the Association of State and Territorial Health Officials (ASTHO). We 
also used our previous work on the capacity of the public health system 
to respond to both bioterrorism and emerging infectious 
diseases.[Footnote 1] We conducted our work in July 2003 in accordance 
with generally accepted government auditing standards.

In summary, infectious disease experts emphasized that no new 
infectious disease control measures were introduced to contain SARS in 
the United States. Instead, strict compliance with and additional 
vigilance to enforce the use of current measures was sufficient. These 
measures--case identification and contact tracing, transmission 
control, and exposure management--are well-established infectious 
disease control measures that proved effective in both health care and 
community settings. The combinations of measures that were used 
depended on either the prevalence of the disease in the community or 
the number of SARS patients served in a health care facility. For SARS, 
case identification within health care settings included screening 
individuals for fever, cough, and recent travel to a country with 
active cases of SARS. Contact tracing, the identification and tracking 
of individuals who had close contact with someone who was infected or 
suspected of being infected, was important for the identification and 
tracking of individuals at risk for SARS. Transmission control measures 
for SARS included contact precautions, especially hand washing after 
contact with someone who was ill, and protection against respiratory 
spread, including spread by large droplets and by smaller airborne 
particles. The use of isolation rooms with controlled airflow and the 
use of respiratory masks by health care workers were key elements of 
this approach. Exposure management practices--isolation and 
quarantine--occurred in both health care and home settings. Effective 
communication among health care professionals and the general public 
reinforced the need to adhere to infectious disease control measures.

While no one knows whether there will be a resurgence of SARS, federal, 
state, and local health care officials we interviewed agree that it is 
necessary to prepare for the possibility. As part of these 
preparations, CDC, along with national associations that represent 
state and local health officials, and others, is involved in developing 
both SARS-specific guidelines for using infectious disease control 
measures and contingency response plans. In addition, these 
associations have collaborated with CDC to develop a checklist of 
preparedness activities for state and local health officials. Such 
preparation efforts also improve the health care system's capacity to 
respond to other infectious disease outbreaks, including those 
precipitated by bioterrorism. However, implementing these plans may 
prove difficult due to limitations in both hospital and workforce 
capacity. A large-scale SARS outbreak could create overcrowding, as 
well as shortages in health care workers and in medical equipment--
particularly respirators.

Background:

SARS is an emerging respiratory disease that has been reported 
principally in Asia, Europe, and North America. SARS is believed to 
have originated in Guangdong Province, China in mid-November 2002. 
However, early cases of the disease went unreported, which then delayed 
identification and treatment of the disease allowing it to spread. On 
February 11, 2003, WHO received its first official report of an 
atypical pneumonia outbreak in China. This report stated that 305 
individuals were affected by atypical pneumonia and that 5 deaths had 
been attributed to the disease. SARS was transmitted out of the 
Guangdong Province on February 21, 2003, by a physician who became 
infected after treating patients in the province. Subsequently, the 
physician traveled to a hotel in Hong Kong and began suffering from 
flu-like symptoms. Days later, other guests and visitors at the hotel 
contracted SARS. As infected hotel patrons traveled to other countries, 
such as Vietnam and Singapore, and sought medical attention for their 
symptoms, they spread the disease throughout each country's hospitals 
as well as in some communities. Simultaneously, the disease began 
spreading around the world along international air travel routes as 
guests from the hotel flew homeward to Toronto and elsewhere.

Description of Severe Acute Respiratory Syndrome:

Scientific evidence indicates that SARS is caused by a previously 
unrecognized coronavirus.[Footnote 2] Transmission of SARS appears to 
result primarily from close person-to-person contact[Footnote 3] and 
contact with large respiratory droplets emitted by an infected person 
who coughs or sneezes. After contact, the incubation period for SARS--
the time it takes for symptoms to appear after an individual is 
infected--is generally within a 10-day period. Clinical evidence to 
date also suggests that people are most likely to be contagious at the 
height of their symptoms. However, it is not known how long after 
symptoms begin that patients with SARS are capable of transmitting the 
virus to others. There is no evidence that SARS can be transmitted from 
asymptomatic individuals.

Currently, there is no definitive test to identify SARS during the 
early phase of the illness, which complicates diagnosing infected 
individuals. As a result, the early diagnosis of SARS relies more on 
interpreting individuals' symptoms and identification of travel to 
locations with SARS transmission. SARS symptoms include fever, chills, 
headaches, body aches, and respiratory symptoms such as shortness of 
breath and dry cough--making SARS difficult to distinguish from other 
respiratory illnesses, such as the flu and pneumonia. The initial 
symptoms can be quite mild, and gradually increase in severity, often 
peaking in the second week of illness. In some individuals, the disease 
might progress to the point where insufficient oxygen is getting to the 
blood.

CDC has established for health care providers criteria used for the 
identification of individuals with SARS, called case 
definitions.[Footnote 4] In the absence of a definitive diagnostic test 
for the disease in its early phase, reported cases of SARS are 
classified into two categories based on clinical and epidemiologic 
criteria--"suspect" and "probable." These case definitions continue to 
be refined as more is learned about this disease. A "suspect" case of 
SARS includes the following criteria:

* high fever,

* respiratory illness, and:

* recent travel to an area with current or previously documented 
suspected transmission of SARS,[Footnote 5] and/or:

* close contact within 10 days of the onset of symptoms with a person 
known or suspected to have SARS.

A "probable" case of SARS includes the following criteria:

* all the criteria for "suspect" cases and:

* evidence in the form of chest x-ray findings of pneumonia, acute 
respiratory distress syndrome (ARDS), or an unexplained respiratory 
illness resulting in death with autopsy findings of ARDS.

The final determination of whether cases meeting the definitions for 
"suspect" and "probable" SARS are due to infection with the SARS virus 
is based on results of testing a blood specimen obtained 28 days after 
the onset of illness.

Furthermore, there is no specific treatment for SARS. In the absence of 
a rapid diagnostic test, it can be very difficult to distinguish 
clinically between individuals with SARS and individuals with atypical 
pneumonia. Therefore, CDC currently recommends that individuals 
suspected of having SARS be managed using the same diagnostic and 
therapeutic strategies that would be used for any patient with serious 
atypical pneumonia. In mild cases of SARS, management at home may be 
appropriate, while more severe cases may require treatment, such as 
intravenous medication and oxygen supplementation, that necessitates 
hospitalization. In 10 to 20 percent of SARS cases, patients require 
mechanical ventilation.[Footnote 6] As of July 11, 2003, the mortality 
rate for SARS was approximately 10 percent, but the mortality rates in 
individuals over 60 years of age approached 50 percent.

As of July 11, 2003, WHO reported that there were an estimated 8,427 
"probable" cases from 29 countries, with 813 deaths from SARS. China, 
Hong Kong, Singapore, Taiwan, and Canada reported the highest number of 
cases. As of July 15, 2003, the United States identified 211 SARS cases 
in 39 states (including Puerto Rico), with no related deaths. Of these 
cases, 175 are classified as "suspect" cases, while 36 are classified 
as "probable."[Footnote 7] In the United States, 34 of the 36 
"probable" cases contracted SARS through international travel. However, 
in the other affected countries, SARS spread extensively among health 
care workers. For example, of the 138 diagnosed cases in Hong Kong as 
of March 25, 2003, that were not due to travel, 85 (62 percent) 
occurred among health care workers; among the 144 cases in Canada as of 
April 10, 2003, 73 (51 percent) were health care workers.

General Infectious Disease Control Measures:

In the United States, the Healthcare Infection Control Practices 
Advisory Committee (HICPAC), a federal advisory committee made up of 14 
infection control experts, develops recommendations and guidelines 
regarding general infectious disease control measures for CDC. 
Important components of these infectious disease control measures are 
the following: case identification and contact tracing, transmission 
control, and exposure management.

Case Identification and Contact Tracing. Case identification and 
contact tracing are considered by health care providers to be important 
first steps in the containment of infectious diseases in both the 
community and health care settings. Case identification is the process 
of determining whether or not a person meets the specific definitions 
for a given disease. Generally, health care providers interview 
patients in order to obtain the history, signs, and symptoms of the 
patient's complaint and perform a physical examination. Tests, such as 
blood tests or x-rays, can be performed to provide additional 
information to help determine the diagnosis. Public awareness of the 
symptoms of a disease can help case identification to the extent that 
individuals who believe they exhibit the symptoms seek medical 
attention. Contact tracing involves the identification and tracking of 
individuals who may have been exposed to a person with a specific 
disease.

Transmission Control. Transmission control measures decrease the risk 
for transmission of microorganisms through proper hand hygiene and the 
use of personal protective equipment, such as masks, gowns, and gloves. 
These measures also include the decontamination of objects and rooms. 
The types of transmission control measures used are based on how an 
illness is transmitted. For example, some categories of transmission 
are as follows:

* Direct contact: person-to-person contact (e.g., two people shaking 
hands) and physical transfer of the microorganism between an infected 
person and an uninfected person.

* Indirect contact: contact with a contaminated object, such as 
secretions from an infected person on a doorknob or telephone receiver.

* Droplet: eye, nose, or mouth of an uninfected person coming into 
contact with droplets (larger than 5 micrometers) containing the 
microorganism from an infected person, for example an infected person 
sneezing without covering his/her mouth with a tissue.

* Airborne: contact with small droplets (5 micrometers or smaller) or 
dust particles containing the microorganism, which are suspended in the 
air.

Exposure Management. Exposure management is the separation of infected 
individuals from noninfected individuals through isolation or 
quarantine. Isolation refers to the separation of individuals who have 
a specific infectious illness from healthy individuals and the 
restriction of their movement to contain the spread of that illness. 
Quarantine refers to the separation and restriction of movement of 
individuals who are not yet ill, but who have been exposed to an 
infectious agent and are potentially infectious.

The success of these infectious disease control measures--case 
identification and contact tracing, transmission control, and exposure 
management--depends, in part, on the frequent and timely exchange of 
information. Public health officials and health care providers need to 
be informed about any modifications of existing infectious disease 
control measures, the geographic progression of an outbreak, and 
reports of disease occurrence. Likewise, elevating public knowledge 
about an infectious disease and its symptoms will enable infected 
individuals to seek medical attention as soon as possible to contain 
the spread.

Experts Recommend Case Identification and Contact Tracing, Transmission 
Control, and Exposure Management Measures To Prevent the Spread of 
SARS:

Infectious disease experts emphasized that existing infectious disease 
control measures played a pivotal role in containing the spread of SARS 
in both health care and community settings. The combinations of 
measures that were used depended on either the prevalence of the 
disease in the community or the number of SARS patients served in a 
health care facility. No new measures were introduced to contain the 
SARS outbreak in the United States; instead, experts said strict 
compliance with and additional vigilance to enforce the use of current 
measures was sufficient. The successful implementation of all of the 
infectious disease control measures depended, in part, on effective 
communication among health care professionals and the general public.

Timely Case Identification and Contact Tracing of SARS Cases Was 
Critical But Difficult:

To prevent the spread of SARS, public health authorities worked to 
identify every individual who might have been infected with the 
disease. Rapid identification of these individuals was critical, but 
the lack of an effective and timely diagnostic test that could be used 
during the early stages of the disease to identify those who actually 
had SARS was an obstacle in halting its spread. Experts acknowledged 
that identification of individuals who might have been infected with 
the SARS virus was likely to include many people who did not have SARS 
because the case definition of an individual with SARS is not highly 
specific and the disease resembles other respiratory illnesses, such as 
pneumonia and the flu. The long incubation period for SARS provided 
health care workers the opportunity to identify cases and close 
contacts of infected individuals before those who actually had the SARS 
virus could spread the disease to others.

An important part of case identification is screening individuals for 
symptoms of a disease. CDC recommended that when individuals called for 
appointments and as soon as possible after the individual arrived in a 
health care setting, all individuals should be screened with targeted 
questions concerning SARS-related symptoms, close contact with a SARS 
suspect case patient, and recent travel. For SARS, public health and 
hospital officials in California and New York said hospital emergency 
room or other waiting room staff routinely used questionnaires to 
screen incoming patients for fever, cough, and travel to a country with 
active cases of SARS. They said that hospitals' signs in various 
locations generally used by incoming patients and visitors also 
included these criteria and asked individuals to identify themselves to 
hospital staff if they met them. According to these officials, an 
individual identified as a potential SARS case generally was given a 
surgical mask and moved into a separate area for further medical 
evaluation. CDC officials said that these measures were also important 
for physicians in private practice. The New York City and California 
health departments used e-mail health alert notices to inform private 
physicians, such as family practitioners and pediatricians, about these 
case identification procedures. These notices directed physicians to 
information posted on the health departments' Web sites. In addition, 
officials from these health departments provided information about SARS 
case identification, among other topics, during local meetings for 
members of the medical community, including physicians in private 
practice.

Toronto, which experienced a much greater prevalence of SARS than the 
United States, used somewhat different case identification practices. 
At the height of the outbreak in Toronto, everyone entering a hospital 
was required to answer screening questions and to have their 
temperature checked before they were allowed to enter. Toronto public 
health department officials said this heightened screening was useful 
for case identification and had an added benefit of educating staff and 
visitors about SARS symptoms. As a further measure, Toronto health 
officials established SARS assessment clinics, also known as fever 
clinics; persons suspecting they might have SARS were asked to go to 
the clinics rather than directly to hospital emergency rooms to avoid 
infecting other individuals. However, officials acknowledged several 
limitations to using these assessment clinics. Because there was no 
follow-up to an initial assessment, some SARS cases that were in the 
early stages were not identified, but later these individuals went to 
hospital emergency rooms. Other difficulties included finding 
physicians to staff the clinics and implementing hospital-level 
infectious disease control measures at these separate clinics. For 
example, some clinics were set up in non-hospital locations--one 
assessment clinic was set up in a tent near a hospital emergency room 
entrance, while another was situated in a hospital ambulance bay where 
emergency personnel transfer patients into the hospital.

Contact tracing--the identification and tracking of individuals who had 
close contact with a "suspect" or "probable" case--is an important 
component of case identification. Contact tracing to identify 
individuals at significant risk for SARS required significant local 
health department resources. In New York City, four teams from the 
communicable disease bureau, comprised of either a physician or nurse 
and several field workers, interviewed each suspect or probable case in 
order to identify contacts. They then called each contact to advise 
them of their exposure and provided information on monitoring for 
symptoms of SARS and receiving treatment if necessary. The calls were 
also to ensure that the contacts were following infection control 
measures in the home. Each contact received routine calls during a 10-
day period--an average of four calls each from a team member. A New 
York City health department official characterized the process of 
contact tracing as labor and time intensive. Standardized forms and 
electronic contact and case databases helped the teams manage contact 
tracing. Additionally, routine weekly meetings with other health 
department divisions ensured that if assistance was needed from these 
departments, they would be up-to-date. Furthermore, New York City 
developed procedure manuals that would allow staff from other 
departments to be trained quickly if needed to assist members of the 
communicable disease bureau. The health department official emphasized 
that the electronic database created to log information about SARS 
contacts was an important tool to facilitate contact tracing. Toronto 
officials agreed that daily contact tracing required a large amount of 
resources. Adding to Toronto's difficulties, its health department did 
not have an electronic case or contact database, but had to rely on 
separate paper files for each individual.

Multiple Transmission Control Measures Used to Contain Spread:

Experts recommended a combination of transmission control measures 
because not all modes of SARS transmission are known. The primary mode 
of transmission is direct person-to-person contact, although contact 
with body fluids and contaminated objects, and possibly airborne 
spread, may play a role. Therefore, multiple infection control 
practices that are used for each type of transmission are included in 
SARS infection control guidelines. Some combination of practices was 
recommended for both health care settings and in the community, with 
more intensive infection control procedures recommended for health care 
settings. According to several experts, the simple "things your mother 
taught you," such as washing your hands and covering your mouth and 
nose with a tissue when sneezing or coughing were effective in reducing 
the spread of SARS.

CDC prepared SARS guidelines for transmission control measures for both 
inpatient (such as hospitals) and outpatient (such as physician 
offices) health care settings.[Footnote 8] These recommendations 
combined what the CDC calls "standard" hospital transmission control 
measures with transmission control measures specific to contact and 
airborne transmission. For the inpatient setting, the guidelines 
included:

* Routine standard precautions, including hand washing. In addition to 
standard precautions, CDC recommended eye protection--such as goggles 
or a face shield.

* Contact precautions, such as the use of a gown and gloves for 
encounters with the patient or his/her environment.

* Airborne precautions, such as an isolation room with negative 
pressure relative to the surrounding area,[Footnote 9] and the use of 
an N-95 filtering disposable respirator for persons entering the room. 
The CDC guidelines suggested that if an isolation room was not 
available, patients should be placed in a private room, and all persons 
entering the room should wear N-95 respirators (or respirators offering 
comparable protection) to protect the wearer from particles expelled by 
a sick person, such as in coughing or sneezing. CDC recommended that, 
where possible, a test to ensure that the N-95 respirators fit properly 
should be conducted. If N-95 respirators were not available for health 
care personnel, then surgical masks should be worn. Generally, the 
material of N-95 respirators is designed to filter smaller particles 
than a surgical mask, and they also are designed to seal more tightly 
to the face.

The health department and hospital officials we spoke with said they 
generally adopted these CDC guidelines for transmission control in 
inpatient settings. Officials said one of the most effective practices 
to contain SARS was frequent hand washing with soap and water. CDC 
guidelines also allow the use of waterless alcohol-based hand rubs 
after coming in contact with "suspect" or "probable" SARS patients or 
their environments. Additionally, a hospital and a health department 
official said careful cleaning of SARS patient rooms was an important 
hygiene measure.

Inpatient facilities in the United States generally saw few SARS 
patients. In New York and California, the hospital officials stated 
that because of the small number of cases that were seen in each 
hospital, usually only one or two at a time, the hospitals were able to 
manage SARS patients in available isolation rooms. Because of the 
greater prevalence of SARS in Toronto, all 22 acute care hospitals were 
directed to have a SARS unit with negative pressure to the rest of the 
hospital, individual rooms, and specific staff who only cared for SARS 
patients. Toronto health department officials later were able to 
designate four hospitals as SARS hospitals and direct all SARS patients 
to these four facilities.

The use of face masks or N-95 respirators was highly recommended by 
experts as an effective means of transmission control for SARS in 
inpatient settings. In one study of health care workers who had 
extensive contact with SARS patients in five Hong Kong hospitals, 
researchers found that no health care worker who consistently used 
either type of face covering became infected.[Footnote 10] Experts also 
noted that the use of N-95 respirators and isolation rooms was 
especially important for high-risk medical procedures, such as 
intubation, where a patient's secretions are likely to be transformed 
into a fine spray and spread for a longer distance than large 
droplets.[Footnote 11] Officials cautioned, however, that there can be 
difficulties in the use of N-95 respirators. One public health official 
said that compliance may be limited in hospitals in several ways--
either staff has never been properly fitted for the respirators, or 
some staff who were fitted many years ago should have a more recent 
fitting. In Canada, Ontario's health ministry directed health care 
workers in the province (which includes Toronto) to employ an 
additional level of protective equipment when conducting high-risk 
medical procedures that was not recommended in the United States. For 
example, health care workers used a protective system that included a 
hood, a full-face respirator, and a complete body covering such as 
long-sleeved floor-length gowns and gloves.

The CDC guidelines for outpatient settings included the same standard 
and contact precautions outlined for inpatient settings. Reflecting the 
different types of facilities likely available in a physician office 
compared to a hospital, for example, outpatient guidelines did not 
advocate the use of specialized isolation rooms. Instead, for 
outpatient settings, the guidelines advised health care personnel to 
separate the potential SARS patient from others in a reception area as 
soon as possible, preferably in a private room with negative pressure 
relative to the surrounding area. At the same time, the guidelines said 
that a surgical mask should be placed over the patient's nose and 
mouth--if this was not feasible, the patient should be asked to cover 
his or her mouth with a disposable tissue when coughing, talking, or 
sneezing.

Transmission control guidelines for community settings incorporated 
many of the same types of measures for containing the spread of SARS as 
recommended for health care settings.[Footnote 12] CDC published SARS 
transmission control guidelines for two community settings--the 
workplace and households. The workplace guidelines recommended frequent 
hand washing with soap and water or waterless alcohol-based hand rubs. 
Along with handwashing, guidelines for household transmission control 
included 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, 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. 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 were 
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 could 
be used by others after routine cleaning, such as washing or laundering 
with soap and hot water.

* Frequent use should be made of common household cleaners for 
disinfecting toilets, sinks, and other surfaces touched by patients 
with SARS.

Exposure Management Used to Prevent SARS Spread:

Exposure management methods such as isolation and quarantine are 
important infectious disease control measures. These measures were 
particularly effective for SARS because of its long incubation period 
during which infected individuals could be isolated before they become 
contagious. In fact, experts stated that isolation of infected 
individuals and quarantine measures used for exposed individuals were 
critical for the containment of SARS.

Isolation of SARS infected individuals occurred in both health care and 
home settings. In Toronto, patients were typically isolated in the 
hospital--even in cases where individuals were not ill enough to need 
hospitalization. During the height of Toronto's outbreak, all 22 acute 
care hospitals were directed to have separate SARS units. On the other 
hand, in the United States, individuals were hospitalized only if they 
needed intensive medical treatment. According to an infectious disease 
expert who consulted with the CDC, this practice was prompted by 
concerns that grouping SARS cases together, such as in a hospital ward, 
could increase the likelihood of spread to both health care workers and 
other hospital patients.

For home isolation in New York City, each patient and contact was given 
detailed information that included instructions on what to do if ill, 
reminders of the importance of calling ahead before going to a 
physician's office or other health care settings, and information on 
how to travel to a health care setting without coming in contact with 
others. These instructions also included guidelines for transmission 
control measures to be used in the home. For all probable cases, the 
New York City health department conducted a home assessment to ensure 
that a SARS patient could be adequately isolated at home, which 
included the need for such things as adequate ventilation and bathrooms 
that would not be shared by noninfected individuals.

Quarantine of exposed individuals was based on different parameters, 
depending on the number of "suspect" or "probable" SARS cases in the 
community. CDC officials said the agency's guidance reflected the fact 
that there was little or no transmission of SARS in the United States, 
and therefore quarantine was less warranted because there were so few 
cases in a community. CDC's guidance advised individuals who were 
exposed but not symptomatic to monitor themselves for symptoms--such as 
fever, a cough, and difficulty breathing, and further advised home 
isolation and medical evaluation if symptoms began. CDC officials also 
advised transfer to a hospital only if the illness became severe.

In contrast, Toronto, which experienced a high level of person-to-
person transmission, used a more conservative quarantine standard. 
Individuals who did not have symptoms but had been in contact with SARS 
infected individuals were ordered to stay in their homes and avoid 
public gatherings for 10 days. Thousands people were asked to undergo 
quarantine in their homes in the Toronto area. During the outbreak, 
exposed Toronto health care workers were restricted to "work 
quarantine"--they were only allowed to travel to and from work alone in 
their vehicles, but they were not allowed to have visitors or visit 
public places. Quarantine efforts in Toronto again required a high 
level of resources. Daily phone calls required 60 staff per 1,000 
people who were quarantined in the Toronto area; these staff worked 7 
days a week to follow up with twice-daily calls to each individual.

Success in Implementing Infectious Disease Control Measures Depended on 
Rapid and Frequent Communication:

According to health officials, rapid and frequent communications of 
crucial information about SARS--such as the level of outbreak worldwide 
and recommended infectious disease control measures--were vital 
components of the efforts to contain the spread of SARS. Since March 
2003, health organizations have shared extensive SARS-related 
information and guidelines with health care workers. For example, WHO 
scheduled numerous press briefings that updated the health community 
about the status of international SARS containment and prevention 
efforts. WHO, with CDC support, sponsored a videoconference broadcast 
globally to discuss the latest findings of the outbreak and prevention 
of transmission in health care settings (which was also available for 
computer download). CDC activated its Emergency Operations Center and 
devoted over 800 medical experts and support personnel worldwide to 
provide round-the-clock coordination and response to the SARS outbreak. 
CDC also had regular conference calls and information-sharing sessions 
with various medical professional associations and state and local 
health departments and laboratories.

At the state level, the California health department utilized the 
California Health Alert Network to send e-mails with SARS information 
(often based on CDC information) to all local health departments and 
many hospitals and physicians. The New York City health department 
hosted a symposium specifically for health care workers, to share the 
latest available SARS information. Hospital officials we spoke with 
also offered training seminars for their health care personnel on the 
signs and symptoms of SARS, recommended screening questions, and 
appropriate infectious disease control measures. Furthermore, 
hospitals kept their patients informed about SARS via posters and 
flyers throughout their facilities, especially in emergency room 
waiting areas.

Health organizations maintained open and frequent communications in the 
community setting to facilitate the containment of SARS. For example, 
in a 2-week period early in the SARS outbreak, CDC conducted nine 
telephone press conferences with the media to keep the public informed 
about the latest SARS information, including numbers of "suspect" and 
"probable" SARS cases, laboratory and surveillance findings, travel 
advisories, and CDC's efforts nationally and worldwide. CDC also 
distributed more than two million health alert notices to travelers 
entering the United States from China, Hong Kong, Singapore, Taiwan, 
Vietnam, or Toronto. These cards, printed in eight languages, asked 
individuals to monitor their health for at least 10 days and to contact 
their health care provider if they exhibited SARS symptoms. A state and 
a local health official also stressed the importance of informing and 
educating the general public in workplaces and schools on the signs and 
symptoms of SARS, an effort which was intended to foster self-
identification, minimize panic, and assuage fears of being infected.

Public health officials also concurred that collaboration between 
federal, state, and local health agencies as well as the medical 
community was crucial in containing the spread of SARS. Through the 
collaboration of all the appropriate players, coordination of 
prevention activities could be maintained, roles could be identified 
and assigned, available resources could be shared, and subsequent 
evaluations could be conducted. For instance, the Toronto health 
department maintained active communications with its local, provincial, 
and national governments in regard to isolation and quarantine 
practices, travel jurisdictions, and other SARS-related matters. The 
health department published directives for all Toronto area health care 
providers, outlining their SARS-related roles and responsibilities. The 
health department also maintained ongoing contact with identified 
liaisons at Toronto hospitals where SARS patients were hospitalized. 
Furthermore, the city of Toronto activated its local emergency 
operations center, which brought together emergency medical services, 
police, and community neighborhood planners to work together to contain 
SARS. Throughout Toronto's efforts, numerous briefings and 
teleconferences were organized to keep all players abreast about the 
latest SARS information in the community.

Federal, State, and Local Health Officials Are Preparing for a Possible 
SARS Resurgence, But Implementing Plans May Pose Challenges if the 
Resurgence Is Large-Scale:

While no one knows whether there will be a resurgence of SARS, federal, 
state, and local health care officials we interviewed agree that it is 
necessary to prepare for the possibility. As part of these 
preparations, CDC, along with national associations that represent 
state and local health officials, and others, is involved in developing 
SARS-specific guidelines for using infectious disease control measures 
and contingency response plans. In addition, these associations have 
collaborated with CDC to develop a checklist of preparedness activities 
for state and local health officials. Such preparation efforts also 
improve the health care system's capacity to respond to other 
infectious disease outbreaks, including those precipitated by 
bioterrorism. However, implementing these plans may prove difficult due 
to limitations in both hospital and workforce capacity. A large-scale 
SARS outbreak could create overcrowding, as well as shortages in 
medical equipment (including N-95 respirators) and in health care 
personnel, who are at higher risk for infection due to their more 
frequent exposure to a contaminated environment.

Federal, State, and Local Health Officials Are Preparing for the 
Possibility of Future Outbreaks:

At the federal level, CDC has begun contingency planning for a SARS 
outbreak, having convened a task force of infection control experts who 
are responsible for developing SARS-specific guidelines and 
recommendations, which address various infection control measures. The 
task force plans to publish its guidelines and recommendations by 
September 2003. CDC is collaborating with several professional 
associations, such as the Council of State and Territorial 
Epidemiologists, ASTHO, and NACCHO, to develop these response plans 
that vary according to the prevalence of the disease and the type of 
setting (i.e., health care or community) in which control measures need 
to be implemented.

At the state and local levels, health departments are also in the 
process of developing contingency response plans for SARS. To 
facilitate this, ASTHO and NACCHO, in collaboration with CDC, published 
a checklist for state and local health officials to use in the event of 
a SARS resurgence. The SARS preparations have been modeled after a 
checklist designed for pandemic influenza. The checklist encompasses a 
broad spectrum of preparedness activities, such as legal issues related 
to isolation and quarantine, strategies for communicating information 
to health care providers, and suggestions for ensuring other community 
partners such as law enforcement and school officials are prepared (see 
app. I for a copy of the checklist).

In specific local preparedness efforts, California and New York, which 
had the highest number of SARS cases in the United States, are also 
preparing for a large-scale SARS outbreak. For example, California 
health department officials said they were developing a plan for surge 
capacity by considering staff rotations or details of health department 
specialists to maintain a high level of response during a potential 
SARS outbreak.[Footnote 13] Similarly, officials with the New York City 
health department said they had created a formal procedure manual, 
which outlines the roles of reallocated staff from various teams in the 
department, to help contain a large-scale SARS outbreak.

Limitations in Hospital and Workforce Capacity Make Implementing 
Infectious Disease Control Measures Difficult in the Event of a Large-
Scale SARS Outbreak:

While hospital officials we spoke with stated that they are taking 
steps to ensure that they have the necessary preparations to address a 
large-scale SARS outbreak, hospitals may still be limited in their 
capacity to respond. Because of the inability to precisely determine if 
someone has SARS, many people may be treated who do not have the virus. 
In the event of a large-scale outbreak, this imprecision may result in 
severe overcrowding in health care settings--especially if a SARS 
resurgence occurs during a peak season for another respiratory disease 
like influenza. This could strain the available capacity of hospitals. 
For example, public health officials with whom we spoke said that in 
the event of a large-scale SARS outbreak, entire hospital wards (along 
with their staff) may need to be used as separate SARS isolation 
facilities. Moreover, certain hospitals within a community might need 
to be designated as SARS hospitals.

We recently reported that most hospitals lack the capacity to respond 
to large-scale infectious disease outbreaks.[Footnote 14] Most 
emergency departments have experienced some degree of crowding and 
therefore, in some cases, may not be able to handle a large influx of 
patients during a potential outbreak of SARS or another infectious 
disease. Few hospitals have adequate staff, medical resources, and 
equipment, such as N-95 respirators, needed to care for the potentially 
large numbers of patients that may seek treatment.[Footnote 15] We 
reported that in the seven cities we visited, hospital, state, and 
local officials indicated that hospitals needed additional equipment 
and capital improvements--including medical stockpiles, personal 
protective equipment, quarantine and isolation facilities, and air 
handling and filtering equipment--to enhance preparedness. According to 
our survey of over 2,000 hospitals,[Footnote 16] the availability of 
medical equipment varied greatly among hospitals, and few hospitals 
reported having the equipment and supplies needed to handle a large-
scale infectious disease outbreak. Half the hospitals we surveyed had, 
for every 100 staffed beds, fewer than 6 ventilators, 3 or fewer 
personal protective equipment suits, and fewer than 4 isolation beds.

Workforce capacity issues may also hinder implementation of infectious 
disease control measures. Health officials noted that there is a lack 
of qualified and trained personnel, including epidemiologists, who 
would be needed in the event of a SARS resurgence. This shortage could 
grow worse if, in the event of a severe outbreak, existing health care 
workers became infected as a result of their more frequent exposure to 
a contaminated environment or became exhausted working longer hours. 
Workforce shortages could be further exacerbated because of the need to 
conduct contact tracing. According to WHO officials, an individual 
infected with SARS came into contact with, on average, 30 to 40 people 
in Asian countries--all of whom had to be contacted and informed of 
their possible exposure. In contrast, New York City health department 
officials said that infected individuals came into contact with 4 
people on average.

In addition, the monitoring of individuals placed under isolation and 
quarantine may strain resources if widespread isolations and 
quarantines are needed. For example, follow-up with isolated or 
quarantined individuals requires significant resources. Officials of 
the New York City Department of Health and Mental Hygiene said that 
they made home visits to SARS cases when officials became concerned 
that these individuals were not following infection control measures or 
were not remaining in their homes. Similarly, Canadian public health 
officials said that they, and in some cases Canadian police, made home 
visits to check compliance with quarantine orders. These officials also 
described the difficulty in providing necessary resources (food, 
medicines, masks, and thermometers) to individuals under isolation or 
quarantine. In Canada, police and the Red Cross had to help deliver 
food to those under isolation or quarantine.

Concluding Observations:

The global spread of SARS was contained through an unprecedented level 
of international scientific collaboration and the use of well-
established infection control measures that have been used effectively 
in the past to control diseases. Although questions remain about SARS, 
especially about the ways it can be transmitted, many lessons were 
learned that could be helpful to the United States in the event of a 
resurgence. Lessons to carry forward are the importance of early 
identification of infected individuals and their contacts, the 
effectiveness of safety precautions to control transmission and ensure 
the protection of health care workers, and the need to use, in some 
cases, isolation and quarantine. Swift and unfettered communication 
among heath care workers, public health officials, government agencies, 
as well as the public provided the essential backbone to support 
ongoing efforts to contain the disease.

Although SARS is currently believed to be contained, now is the time to 
prepare for the possibility of a future outbreak. Some preparations are 
already underway and encompass, in large part, approaches similar to 
those for pandemic influenza and are also part of general bioterrorism 
preparedness. Worldwide disease surveillance would facilitate prompt 
identification of a resurgence of SARS, allowing rapid implementation 
of infectious disease control measures that would reduce both the 
spread of SARS and the risk of a large outbreak. Should a large-scale 
outbreak occur in the near term, limitations in the capacity of our 
nation's health system to undertake effective and rapid implementation 
of infectious disease control measures could prove problematic. A major 
SARS outbreak would necessitate rapid escalation of infectious disease 
control resources including health care workers, emergency room and 
hospital capacity, and the requisite control and support equipment.

Mr. Chairman, this completes my prepared statement. I would be happy to 
respond to any questions you or other Members of the Subcommittee may 
have at this time.

Contact and Staff Acknowledgments:

For more information regarding this testimony, please contact Marjorie 
Kanof at (202) 512-7101. Bonnie Anderson, Karen Doran, John Oh, 
Danielle Organek, and Krister Friday also made key contributions to 
this statement.

[End of section]

Appendix I: SARS Preparedness Checklist:

[See PDF for image]

[End of section]

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FOOTNOTES

[1] U.S. General Accounting Office, SARS Outbreak: Improvements to 
Public Health Capacity Are Needed for Responding to Bioterrorism and 
Emerging Infectious Diseases, GAO-03-769T (Washington, D.C.: May 7, 
2003).

[2] The coronavirus is one of a group of viruses that are responsible 
for some but not all common colds. They are so named because their 
microscopic appearance is that of a virus particle surrounded by a 
crown.

[3] Close contact is usually defined as having cared for, lived with, 
or having direct contact with bodily secretions of an infected 
individual.

[4] See Centers for Disease Control and Prevention, Department of 
Health and Human Services, Updated Interim U.S. Case Definition for 
Severe Acute Respiratory Syndrome (SARS) (Atlanta, Ga.: July 16, 2003).

[5] The last date for illness onset is 10 days (i.e., one incubation 
period) after removal of a CDC travel alert. To be considered a suspect 
case, an individual's travel would have occurred on or before the last 
date the travel alert was in place. 

[6] Mechanical ventilation involves artificial ventilation of the lung 
using means external to the body. A mechanical ventilator is a machine 
that generates a controlled flow of gas (a mixture of oxygen and air) 
into a patient's airways. 

[7] Additionally, on July 16, 2003, CDC revised the case definition to 
exclude individuals with negative test results for SARS coronavirus. 
This resulted in 207 previously identified SARS cases (169 suspect 
cases and 38 probable cases) being removed from the count of SARS cases 
in the United States.

[8] See Centers for Disease Control and Prevention, Department and 
Health and Human Services, Updated Interim Domestic Infection Control 
Guidance in the Health-Care and Community Setting for Patients with 
Suspected SARS (Atlanta, Ga.: May 1, 2003).

[9] Negative pressure rooms generally are private rooms in which air 
flow is from the hallway into the room, and then outdoors. 

[10] See W.H. Seto, et.al., Effectiveness of precautions against 
droplets and contact in prevention of nosocomial transmission of severe 
acute respiratory syndrome (SARS), The Lancet (Vol. 361, May 3, 2003), 
pp. 1519-20.

[11] Generally, intubation is the introduction of a tube into an 
individual's airway to facilitate breathing.

[12] See Centers for Disease Control and Prevention, Department of 
Health and Human Services, Interim Guidance on Infection Control 
Precautions for Patients with Suspected Severe Acute Respiratory 
Syndrome (SARS) and Close Contacts in Households (Atlanta, Ga.: Apr. 
29, 2003).

[13] Surge capacity is the ability of the health care system to handle 
a large number of patients.

[14] U.S. General Accounting Office, SARS Outbreak: Improvements to 
Public Health Capacity Are Needed for Responding to Bioterrorism and 
Emerging Infectious Diseases, GAO-03-769T (Washington D.C.: May 7, 
2003).

[15] Shortages in N-95 respirators occurred during the SARS outbreak 
because of the high demand. CDC officials said that shortages in the 
United States may have been due to high demand in other countries, 
particularly when WHO recommended that health care workers in all 
affected countries use N-95 respirators.

[16] Between May and September 2002, we surveyed over 2,000 short-term, 
nonfederal general medical and surgical hospitals with emergency 
departments located in metropolitan statistical areas. (See U.S. 
General Accounting Office, Hospital Emergency Departments: Crowded 
Conditions Vary among Hospitals and Communities, GAO-03-460 
(Washington, D.C.: Mar. 14, 2003) for information on the survey 
universe and development of the survey.) For the part of the survey 
that specifically addressed hospital preparedness for mass casualty 
incidents, we obtained responses from 1,482 hospitals, a response rate 
of about 73 percent.

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