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Severe Acute Respiratory Syndrome (SARS)

Severe acute respiratory syndrome (SARS) is a condition that was described in patients in Asia, North America, and Europe. A final report issued by the CDC in October 2003 identified 164 cases in the United States ¹. The majority of patients identified as having SARS were adults aged 25–70 years who were previously healthy. Few suspected cases of SARS were reported among children aged <15 years ².

Cause of SARS

SARS is caused by a new coronavirus, called SARS-associated coronavirus (SARS-CoV). The CDC and others have developed new tests for detecting SAR-CoV. Current tests include serum antibody tests, reverse transcription-polymerase chain reaction (RT-PCR) tests, and viral isolation for SARS-CoV ³. CDC has made reagents for SARS coronavirus antibody testing available to state public health laboratories.

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Common Questions and Answers

The ADA has put together a list of common questions about SARS and their answers based on information available from the Spring 2003 outbreak.

Can I ask the patient about recent travel or recent respiratory disease as a part of the health history review?

CDC has recommended asking patients targeted screening questions concerning fever, respiratory symptoms, and recent travel ⁶.

If I were exposed to SARS, how long would it take me to become sick?

The incubation period is 2–7 days. However, it may take as long as 10 days for the illness to begin ².

How does the disease spread?

Close contact with patients is the main route of transmission. CDC defines this close contact as caring for, living with, or getting in direct contact with respiratory secretions and body fluids of people with SARS. SARS is mainly a droplet infection, but it is possible that SARS may be transmitted as an airborne infection ⁴.

Can infection be transferred by saliva?

There is no information available at this time regarding saliva as a means of transmission. However, the CDC stated that coming in contact with respiratory secretions or body fluids of people with SARS have caused transmission. Until more is known about the disease, a precautionary approach such as the use of gloves, surgical masks and gowns when treating dental patients is warranted ⁴.

What is the potential for infection of dental staff?

There is no data available about transmission of SARS to dental staff. However, CDC has reported that aerosol-generating procedures that induce coughing may facilitate transmission of the SARS. The examples given by the CDC include bronchoscopy, airway suction, and endotracheal intubation ⁷. Since dental personnel come in close contact with dental patients, a precautionary approach is warranted.

How can we find out whether a patient is a carrier (in the incubation period)?

A SARS carrier does not usually show clinical manifestations. The illness usually begins with a fever (temperature greater than 100.4°F). The fever is sometimes associated with chills or flu-like symptoms, including headache, general feeling of discomfort, and body aches ⁴.

What preventive measures should we take?

The keys to SARS prevention are early detection of cases, containment of infection, protection of personnel, and hand hygiene. The dental office should implement infection protocol strategies to protect personnel and patients from SARS. Those strategies should include:

Administrative measures:

A. Educate dental personnel about SARS. The learning protocol should include SARS specific infection control, case identification, and screening patients for SARS (by asking questions).

B. Periodically check the Center of Disease Control and Prevention web site at http://www.cdc.gov/ncidod/sars/index.htm and the World Health Organization web site at http://www.who.int/csr/sars/en/ for the latest news about SARS.

C. Periodically check the web site of your local or state health department for the latest epidemiological information in your community.

D. Implement and enforce infection control measures.

E. Place visual signs in the reception area and operatories advising patients to notify the dentist or dental personnel if they have fever or respiratory symptoms.

F. Modify health history questionnaires to include targeted screening questions and make sure that questions are asked to every patient at every visit. Questions may include:

• Do you have a recent onset of a respiratory problem like cough or difficulty breathing?
• Have you had an international travel in the past 10 days?
• Have you come in contact with a SARS patient in the past 10 days?

If a patient answered “yes” to the clinical question and any of the exposure questions, put on a surgical mask, discuss the potential concerns with the patient, call a medical facility and notify it that you are sending a patient so that arrangements can be made for care and transport of the patient.

It is important that all patients are asked the same screening questions and that the response to answering be consistent. Failure to do so may be misconstructed as a pretext for discrimination.

Limiting screening questions to only select patient populations can undermine early detection efforts and, depending on the specific facts involved, might be misconstrued as pretext for discrimination.

Engineering measures:

• Make sure the dental office has good ventilation.

Dental Personnel Protection

A. Protective attire should include:

• Disposable gloves (latex or vinyl) which must be changed after every patient.
• Surgical masks and goggles. Using a plastic face shield without a mask does not offer enough protection Make sure the mask covers the mouth and the nose ⁹.
• Reusable or disposable gowns.

B. Cleaning and disinfection.

• Any EPA-registered hospital detergent-disinfectant currently used by healthcare facilities for environmental sanitation may be used. Manufacturer’ recommendations for use-dilution (i.e., concentration), contact time and care in handling should be followed ¹⁰.

C. Hand Hygiene:

Wash hands with soap and water between patients. An alcohol-based hand rub may be used if the hand is not soiled.

What can we do if informed that a person who has just been seen in the office got ill with SARS? Should we notify other patients? What should the exposed staff members do?

The World Health Organization has recommended that contacts be managed as follows: ¹¹

• Give information on SARS to the contact, including personnel and any person who came in contact with the patient while in the office.
• Notify your local or state health department.
• Advise the contact to consult with a healthcare professional immediately as the contact will need to be monitored on daily basis (including daily recording of temperature and respiratory symptoms.)
• The contact does not need to be in isolation.
• If the contact develops symptoms, immediate medical care at a healthcare facility is recommended.
• The most consistent first symptom that is likely to appear is fever.

CDC has recommended the following protocol for healthcare workers following an unprotected contact with a SARS patient:

• Exclusion from duty is not recommended for dental personnel after exposure if they don't have fever or respiratory symptoms.
• The same rule applies to dental personnel or dental students who have traveled to an area with documented or suspected community transmission of SARS.
  However, the healthcare worker should report any unprotected contact to facility management ¹².
• Active surveillance for fever and respiratory symptoms (daily) of healthcare workers who had unprotected exposure with SARS patient ¹⁰.
• Exclusion from duty is recommended for healthcare workers if fever or respiratory symptoms develop during the 10 days following unprotected exposure to SARS patients. However, if symptoms do not progress to resemble the case definition (described under title: identifying the SARS Patient), the person may be allowed to return to work after consultation with a healthcare provider.
• If symptoms progress to resemble the case definition, then the person should be excluded from work until 10 days after the resolution of fever, provided respiratory symptoms are absent or improving. Suspected SARS should be reported to local health authorities and healthcare providers immediately. The person should also limit interactions outside the home and should not go to school, out-of-home child care, church, or other public areas and should seek healthcare evaluation.
• Passive surveillance (review of occupational health) for all healthcare professionals working in a facility with a SARS patient (as in hospitals)⁹.

Should we use a respirator?

A surgical mask and protective eyewear is all you need to care for dental patients. An N95 respirator (that is cleared by FDA for medical use) is only recommended for healthcare workers caring for SARS patients. However, due to the quick course of the disease, it appears unlikely that the dentist will encounter a SARS patient in the dental office.

How can we manage a SARS patient in the dental office?

A SARS patient should not be treated in the dental office. If you encounter a potential SARS patient, you should send the patient to a healthcare facility or a physician for diagnosis and care. As a dental healthcare professional, you also have the duty to report the case to your state or local health departments¹³.

How soon can I care for a patient after she recovers from SARS?

According to the WHO, until more is known about the etiological agent, and the risk of continuing transmission, convalescent cases should remain at home for 7 days following discharge from hospital. During this period they should stay indoors, keeping contact with others to a minimum¹⁴.

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Identifying the SARS Patient

Due to the quick course of the disease, it appears unlikely that dentists will encounter SARS patients in the dental office. Patients develop severe respiratory symptoms and radiographic evidence of pneumonia in as little as two days. If you encounter a potential SARS patient, you should immediately send the patient to a medical facility for diagnosis and care. A SARS patient should not be treated in the dental office.

The dentist, as a healthcare professional, should know how to identify a suspected case of SARS.

According to the CDC ⁵, the SARS case can be defined as follows:

• Probable case: meets the clinical criteria for severe respiratory illness of unknown etiology and epidemiologic criteria for exposure; laboratory criteria confirmed, negative, or undetermined.
• Suspect case: meets the clinical criteria for moderate respiratory illness of unknown etiology, and epidemiologic criteria for exposure; laboratory criteria confirmed, negative, or undetermined.

• Asymptomatic or mild respiratory illness
• Moderate respiratory illness
  • Temperature of >100.4º F (>38º 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 >100.4º F (>38º 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 or recently 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 infection. Close contact is defined as having cared for, having lived with, or having direct contact with respiratory secretions and/or body fluids of a person identified as a suspect SARS case.

Laboratory Criteria

• Confirmed
  • Detection of antibody to SARS-CoV in specimens obtained during acute illness or >21 days after illness onset, or
  • Detection of SARS-CoV RNA by RT-PCR confirmed by a second PCR assay, by 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 convalescent serum obtained >21 days after symptom onset
• Undetermined: laboratory testing either not performed or incomplete
  Areas with documented or suspected community transmission of SARS: Peoples Republic of China (i.e., mainland China and Hong Kong Special Administrative Region); Taiwan; Hanoi, and Toronto, Canada.

Areas with documented or suspected community transmission of SARS:

Peoples Republic of China (i.e., mainland China and Hong Kong Special Administrative Region); Taiwan; Hanoi, and Toronto, Canada.

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Incubation Period

The incubation period for SARS is 2–7 days; however, isolated reports have suggested an incubation period as long as 10 days². The duration of time before or after onset of symptoms during which a patient with SARS can transmit the disease to others is unknown.

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Routes of Transmission

The primary way that SARS appears to spread is by close person-to-person contact. Close contact might occur when people live together in the same household or if someone is providing care to a SARS patient. Potential ways in which SARS can be spread include touching the skin of other people or objects that are contaminated with infectious droplets and then touching your eye(s), nose, or mouth. This can happen when someone who is sick with SARS coughs or sneezes droplets onto themselves, other people, or nearby surfaces. It also is possible that SARS can be spread more broadly through the air or by other ways that are currently not known ⁴. In the United States, there was no indication of community transmission⁴.

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The following files and links to other sites opening a separate browser window. You may need to disable your pop-up blocker for these links to work properly.

¹ Severe Acute Respiratory Syndrome: Report of Cases in the United States. Center for Disease Control and Prevention. http://www.cdc.gov/od/oc/media/sars/cases.htm. Information retrieved on December 8, 2003.

² Preliminary Clinical Description of Severe Acute Respiratory Syndrome. MMWR. March 21, 2003. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5212a5.htm. Retrieved on April 22, 2003.

³ Fact Sheet for Clinicians: Interpreting SARS Test Results from CDC and Other Public Health Laboratories. CDC. May 30, 2003. http://www.cdc.gov/ncidod/sars/testresultsc.htm. Accessed on May 30, 2003.

⁴ Frequently Asked Questions. CDC. April 4, 2003. http://www.cdc.gov/ncidod/sars/faq.htm.
Retrieved on April 22, 2003

⁵ Severe Acute Respiratory Syndrome (SARS) Updated Interim Case Definition. CDC. April 30, 2003. http://www.cdc.gov/ncidod/sars/casedefinition.htm. Retrieved on April 30, 2003.

⁶ Triage of Patients Who May Have Severe Acute Respiratory Syndrome: Interim Guidance for Screening in Ambulatory Care Settings. CDC, March 25, 2003. http://www.cdc.gov/ncidod/sars/triage_interim_guidance.htm. Retrieved on May 30, 2003.

⁷ Infection Control Precautions for Aerosol-Generating Procedures on Patients who have Suspected Severe Acute Respiratory Syndrome (SARS). CDC. March 20, 2003. http://www.cdc.gov/ncidod/sars/aerosolinfectioncontrol.htm. Retrieved on May 30, 2003.

⁸ Chiarello, L. Preventing the Spread of Severe Acute Respiratory Syndrome (SARS). CDC Webcast. April 4, 2003.

⁹ Chiarello, L. Increasing clinical Preparedness for Severe Acute Respiratory Syndrome (SARS). CDC Webcat, May 8, 2003.

¹⁰ Interim Domestic Guidance for Cleaning and Disinfection of the SARS Patient Environment.CDC April 28, 2003. http://www.cdc.gov/ncidod/sars/cleaningpatientenviro.htm. Retrieved on May 1, 2003

¹¹ Management of Severe Acute Respiratory Syndrome (SARS). WHO. March 28, 2003. http://www.who.int/csr/sars/management/en/. Retrieved on April 22, 2003.

¹² Interim Domestic Guidance for Management of Exposures to Severe Acute Respiratory Syndrome (SARS) for Healthcare and Other Institutional Settings. CDC. March 27, 2003. http://www.cdc.gov/ncidod/sars/ic-closecontacts.htm. Retrieved on April 22, 2003

¹³ Reporting. CDC, March 24, 2003. http://www.cdc.gov/ncidod/sars/reporting.htm. Retrieved on April 22, 2003.

¹⁴ WHO hospital discharge and follow-up policy for patients who have been diagnosed with Severe Acute Respiratory Syndrome (SARS). WHO, 28 March 2003. http://www.who.int/csr/sars/discharge/en/. Retrieved on April 22, 2003.

(Updated 12/08/03)

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