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    CDC Now Concerned SARS May Spread More Easily Than First Thought; Travelers Who Just Passed Thru Affected Asian Areas En Route Now Being Alerted; Will Involve 23 U.S. Ports of Entry

    (March 29, 2003) -- In a disturbing development indicating the alarming flu/pneumonia SARS (Severe Atypical Respiratory Syndrome) may spread more easily than first thought, the Centers for Disease Control & Prevention said today that while it still believes the major mode of SARS transmission is droplets when an infected person coughs or sneezes, "we are [now also] concerned about the possibility of airborne transmission across broader areas and also the possibility that objects that become contaminated in the environment could serve as modes of spread."

    In other words, CDC is concerned that things can become contaminated and spread the disease to people touching those things.

    And in news affecting those who travel internationally and communities dealing with them, CDC Director Dr. Julie Gerberding indicated that people who simply transited en route through affected Asian areas might also be at risk. She said she thinks "travelers at risk for SARS are those who have been in mainland China, in Hong Kong, in Hanoi and in Singapore" and pointedly added:

    [W]e recognize that there are passengers who moved through these areas for brief periods of times and are arriving here in this country indirectly, after being in those countries, so right now we are meeting both direct incoming flights from the affected areas as well as passengers who are arriving from different regions and have passed through those areas en route.

    ...We also are updating our guidance to travelers. I think that the travelers at risk for SARS are those who have been in mainland China, in Hong Kong, in Hanoi and in Singapore.

    However, we recognize that there are passengers who moved through these areas for brief periods of times and are arriving here in this country indirectly, after being in those countries, so right now we are meeting both direct incoming flights from the affected areas as well as passengers who are arriving from different regions and have passed through those areas en route.

    The alerting is being expanded to include arriving passengers from China, from mainland China, and from Singapore at this point in time."

    Dr. Gerberding said:

    [F]rom the standpoint of CDC, I would say that we are very concerned about the spread of this virus, particularly in Asia...[I]t is a respiratory virus, it does appear to be transmitted very efficiently, and what we know about respiratory viruses suggests that the potential for infecting large numbers of people is very great.

    So we may be in the very early stages of what could be a much larger problem as we go forward in time. On the other hand, this is new, we don't know everything about it, and we have a lot of questions about the overall spread...

    In Hong Kong, the situation is particularly alarming because we have several hospitals that are affected, and there are so many health care workers in each of these hospitals that could have been exposed or who are developing SARS, that there's already a multiplier in the community. Every health care worker has household contacts, those contacts, when they become ill, have had other exposures.

    ...The biggest unknown is of course what is going on in China and we are desperate to learn more about the scope and magnitude of the problem there, because that really I think will be the biggest predictor for where this will be headed over the next few weeks.

    Dr. Gerberding also noted that the number of suspected U.S. cases, which (as reported by stood at 59 yesterday...was now 62.

    And she noted:

    [A]lthough the World Health Organization (WHO) isn't issuing travel restrictions, and CDC isn't doing so either, "WHO has...implemented procedures for screening passengers before they leave the country of SARS origin. They're asking countries to evaluate departing passengers for respiratory illnesses or other signs that could represent SARS. In part, this is because there are some early reports that passengers traveling with a SARS patients on board could be at risk for acquiring this infection, and we don't want to have any cases acquired during flight or during transfer on a ship or other vehicle."

    Dr. Gerberding indicated "the travel alerting process that's already been in place, and actually we've issued more than 150,000 alerts, is being expanded and will be involving 23 ports of entry into the United States." She added that "Taiwan is a country that is reporting cases and they are included in the travel advisory for incoming passengers."

    She explained:

    "What we are doing when passengers arrive at the 23 ports of entry involved in this alerting process in the United States is delivering to the passengers at the time that they're disembarking a health alert card, a small card that we now have translated into six languages, that advises them to be alert of any evidence of fever or respiratory symptoms for the ten days after they've left one of the SARS countries. The card specifically mentions the countries of concern.

    In addition, there's a second section of the card that is information to clinicians, so if SARS patient does seek clinical attention, the clinician understands, they bring the card in and it gives them the specific advice, provides them information on how to get more up-to-date information on SARS, and also how to contact CDC and the importance of reporting any known or suspect cases.

    So it's a mechanism to remind people at the point of departure, that they've been in an area where they could possibly have come in contact with someone with SARS and that they need to be alert to the earliest possible symptoms, so that they can get care and protect others.

    [adding later]...So our approach is primarily alerting people on their way back home, or on their way to the United States from these areas, and secondarily, to issue the generic statement that if you're traveling to this region you may wish to defer elective travel until such time that we know more and can do a more thorough assessment of what risks are present.

    We are not medically screening incoming passengers but if a passenger is identified as having illness on a plane or a ship, they are met by the health authorities in that state, in conjunction with the CDC officials, and they are evaluated and we have done that several times.

    So if there is evidence of a symptomatic person, on arrival they are assessed, and if necessary, the other passengers are evaluated and they're monitored prospectively, to make sure that they haven't been exposed as they go forward through the incubation period.

    As separately reported by, the CDC reported that as of March 28 , CA has 12 suspected SARS cases under investigation, the largest number of any state..

    Noting the large number of CA cases, Dr. Gerberding said, "the largest number of patients are in California. That's not surprising since California is one of our largest states. But that's also a point of a lot of travel to Asia and so it makes demographic sense, that that would be an area where there would be perhaps an increased risk."

    The CDC has not said where in CA the 12 suspected SARS cases are. On March 21, CA had 6 suspected cases. As previously reported by, L.A. County health officials reported on March 17 that they were investigating one suspected case in Los Angeles County.

    Dr. Gerberding ended with one piece of somewhat better news: "If there's any good news in SARS right now, it's that the majority of patients do appear to recover and that the death rate is actually lower than what we see with epidemic influenza, about 3.5 percent of the patients have died from the illness. That is still a tragic occurrence for the people who are affected, and their families, and I would never mean to minimize it. But it is fortunate that it is not even more severe."

    The CDC website ( devotes a special page to detailed information on SARS. Readers should check the CDC SARS page for updates on this rapidly developing story.

    CDC's SARS pages also includes a travel advisory updated on March 28.

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