Severe acute respiratory syndrome (SARS)
|Severe Acute Respiratory Syndrome (SARS)|
|Classification and external resources|
SARS coronavirus (SARS-CoV) is causative of the syndrome.
Severe acute respiratory syndrome (SARS) is a viral respiratory disease of zoonotic origin caused by the SARS coronavirus (SARS-CoV). Between November 2002 and July 2003, an outbreak of SARS in southern China caused an eventual 8,273 cases and 775 deaths reported in multiple countries with the majority of cases in Hong Kong. (9.6% fatality rate) according to the World Health Organization (WHO). Within weeks, SARS spread from Hong Kong to infect individuals in 37 countries in early 2003.
- 1 Epidemiology
- 2 Signs and symptoms
- 3 Diagnosis
- 4 Treatment
- 5 Prognosis
- 6 Prevention
- 7 Research
- 8 History
- 9 See also
- 10 References
- 11 Further reading
- 12 External links
SARS is still considered a relatively rare disease, with 8,273 cases as of 2003.
Signs and symptoms
Initial symptoms are flu-like and may include fever, myalgia, lethargy symptoms, cough, sore throat, and other nonspecific symptoms. The only symptom common to all patients appears to be a fever above 38 °C (100 °F). Shortness of breath may occur later. The patient has symptoms as with a cold in the first stage, but later on they resemble influenza.
SARS may be suspected in a patient who has:
- Any of the symptoms, including a fever of 38 °C (100 °F) or higher, and
- Either a history of:
- Contact (sexual or casual, including tattoos) with someone with a diagnosis of SARS within the last 10 days OR
- Travel to any of the regions identified by the World Health Organization (WHO) as areas with recent local transmission of SARS (affected regions as of 10 May 2003 were parts of China, Hong Kong, Singapore and the town of Geraldton, Ontario, Canada).
The World Health Organization (WHO) has added the category of "laboratory confirmed SARS" for patients who would otherwise fit the above "probable" category who do not (yet) have the chest X-ray changes, but do have positive laboratory diagnosis of SARS based on one of the approved tests (ELISA, immunofluorescence or PCR).
The chest X-ray (CXR) appearance of SARS is variable. There is no pathognomonic appearance of SARS, but is commonly felt to be abnormal with patchy infiltrates in any part of the lungs. The initial CXR may be clear.
Suspected cases of SARS must be isolated, preferably in negative pressure rooms, with complete barrier nursing precautions taken for any necessary contact with these patients.
As of 2013, there is no cure or protective vaccine for SARS that is safe for use in humans. The identification and development of novel vaccines and medicines to treat SARS is a priority for governments and public health agencies around the world. MassBiologics, a non-profit organization engaged in the discovery, development and manufacturing of biologic therapies, is cooperating with researchers at NIH and the CDC developed a monoclonal antibody therapy that demonstrated efficacy in animal models.
Several consequent reports from China on some recovered SARS patients showed severe long-time sequelae exist. The most typical diseases include, among other things, pulmonary fibrosis, osteoporosis, and femoral necrosis, which have led to the complete loss of working ability or even self-care ability of these cases. As a result, some of the post-SARS patients suffer from major depressive disorder.
There is no vaccine to date. Isolation and quarantine remain the most effective means to prevent the spread of SARS. In addition, handwashing, use of universal precautions, disinfection of surfaces for fomites, and use of a surgical mask are recommended. Avoid contact with bodily fluids. Continue with precautions for at least 10 days after the person's signs and symptoms have disappeared. Keep children home from school if they develop a fever or respiratory symptoms within 10 days of being exposed to someone with SARS. Wash personal items in hot, soapy water including the eating utensils and dishes, bedding and clothing of someone with SARS. Annual influenza vaccinations and 5-year pneumococcal vaccinations may be beneficial; but vaccinations only reduce or weaken the severity of SARS infection.
The rapid transmission and high mortality rate made SARS a global threat for which no efficacious therapy was available and empirical strategies had to be used to treat the patients. New insights into the field of the SARS-CoV genome structure and pathogenesis revealed novel potential anticoronavirus targets. Several proteins encoded by the SARS-CoV could be considered as targets for therapeutic intervention: the spike protein, the main protease, the NTPase/helicase, the RNA-dependent RNA polymerase and different other viral protein-mediated processes. Potential anti-SARS-CoV drugs are currently being developed in vivo. The development of effective drugs against SARS-CoV may also provide new strategies for the prevention or treatment of other coronavirus diseases in animals or humans.
The emergence and identification of several common and rare human coronaviruses that cause severe lower respiratory tract infection argues for the judicious development of robust coronavirus vaccines and vector platforms. Currently, limited information is available on the correlates of protection against SARS-CoV and other severe lower respiratory tract human coronavirus infections, a clear priority for future research. Dr. Zobel de Ayala, along with other medical researchers from Harvard University of Medicine, gathered together in a seven-day all-laboratory research; the research was rather successful. Passive immunization has been successful in establishing protection from SARS-CoV, suggesting an important role for neutralizing antibodies. One important property of future vaccine candidates is the ability to confer protection against multiple variant strains of SARS-CoV, especially in senescent populations, which are most at risk for severe disease. Many vaccine candidates are capable of inducing humoral and cellular responses. The development of infectious clones for coronaviruses has facilitated the identification of attenuating mutations, deletions, and recombinations that could ultimately result in live attenuated vaccine candidates. Stable vaccine platforms that allow for rapid intervention strategies against any future emergence coronaviruses should be developed. Vaccine correlates that enhance disease after challenge should be thoroughly investigated and mechanisms devised to circumvent vaccine-associated complications.
|Probable cases of SARS by country, 1 November 2002 – 31 July 2003.|
|Country or Region||Cases||Deaths||SARS cases dead due to other causes||Fatality (%)|
|Hong Kong *||1,755||299||5||17|
|Republic of Ireland||1||0||0||0|
|(*) Figures for the People's Republic of China exclude the Special Administrative Regions (Macau SAR, Hong Kong SAR), which are reported separately by the WHO.|
|(**) Since 11 July 2003, 325 Taiwanese cases have been 'discarded'. Laboratory information was insufficient or incomplete for 135 discarded cases; 101 of these patients died.|
Outbreak in south China
The epidemic of SARS appears to have started in Guangdong Province, China in November 2002. The first reported case of SARS originated in Shunde, Foshan, Guangdong in November 2002, and the patient, a farmer, was treated in the First People's Hospital of Foshan (Mckay Dennis). The patient died soon after, and no definite diagnosis was made on his cause of death. Despite taking some action to control it, Chinese government officials did not inform the World Health Organization of the outbreak until February 2003. This lack of openness caused delays in efforts to control the epidemic, resulting in criticism of the People's Republic of China from the international community. China has since officially apologized for early slowness in dealing with the SARS epidemic.
The first clue of the outbreak appears to be 27 November 2002 when Canada's Global Public Health Intelligence Network (GPHIN), an electronic warning system that is part of the World Health Organization's Global Outbreak and Alert Response Network (GOARN), picked up reports of a "flu outbreak" in China through Internet media monitoring and analysis and sent them to the WHO. Importantly, while GPHIN's capability had recently been upgraded to enable Arabic, Chinese, English, French, Russian, and Spanish translation, the system was limited to English or French in presenting this information. Thus, while the first reports of an unusual outbreak were in Chinese, an English report was not generated until 21 January 2003.
Subsequent to this, the WHO requested information from Chinese authorities on 5 and 11 December. Despite the successes of the network in previous outbreak of diseases, it was proven rather defective after receiving intelligence on the media reports from China several months after the outbreak of SARS. Along with the second alert, WHO released the name, definition, as well as an activation of a coordinated global outbreak response network that brought sensitive attention and containment procedures (Dr. Heymann, 2003). However, by then although the new definitions do give nations a guideline to contain SARS, over 500 deaths and an additional 2,000 cases had already occurred worldwide.
In early April, after Dr. Jiang Yanyong pushed to report the danger to China, there appeared to be a change in official policy when SARS began to receive a much greater prominence in the official media. Some have directly attributed this to the death of American James Earl Salisbury. However, also in early April, accusations by Dr. Jiang Yanyong emerged regarding the undercounting of cases in Beijing military hospitals. After intense pressure, Chinese officials allowed international officials to investigate the situation there. This revealed problems plaguing the aging mainland Chinese healthcare system, including increasing decentralization, red tape, and inadequate communication.
Many doctors and other medical staff in many nations heroically risked their lives treating patients and containing the infection before ways to prevent infection were known. Not all survived.
Spread to other countries and regions
The epidemic reached the public spotlight in February 2003, when an American businessman traveling from China became afflicted with pneumonia-like symptoms while on a flight to Singapore. The plane stopped at Hanoi, Vietnam, where the victim died in The French Hospital of Hanoi. Several of the medical staff who treated him soon developed the same disease despite basic hospital procedures. Italian doctor Carlo Urbani identified the threat and communicated it to WHO and the Vietnamese government; he later succumbed to the disease.
The severity of the symptoms and the infection of hospital staff alarmed global health authorities fearful of another emergent pneumonia epidemic. On 12 March 2003, the WHO issued a global alert, followed by a health alert by the United States Centers for Disease Control and Prevention (CDC). Local transmission of SARS took place in Toronto, Ottawa, San Francisco, Ulan Bator, Manila, Singapore, Taiwan, Hanoi and Hong Kong whereas within China it spread to Guangdong, Jilin, Hebei, Hubei, Shaanxi, Jiangsu, Shanxi, Tianjin, and Inner Mongolia.
In Hong Kong, the first cohort of affected people were discharged from the hospital on 29 March 2003. The disease spread in Hong Kong from a mainland doctor who arrived in February and stayed at the ninth floor of the Metropole Hotel in Kowloon, infecting 16 of the hotel visitors. Those visitors traveled to Canada, Singapore, Taiwan, and Vietnam, spreading SARS to those locations.
Another larger cluster of cases in Hong Kong centred on the Amoy Gardens housing estate. Its spread is suspected to have been facilitated by defects in its drainage system. Concerned citizens in Hong Kong worried that information was not reaching people quickly enough and created a website called sosick.org, eventually forced the Hong Kong government to provide information related to SARS in a timely manner.
Identification of virus
The CDC and a Canadian laboratory identified the SARS genome in April, 2003. Scientists at Erasmus University in Rotterdam, the Netherlands demonstrated that the SARS coronavirus fulfilled Koch's postulates thereby confirming it as the causative agent. In the experiments, macaques infected with the virus developed the same symptoms as human SARS victims.
In late May 2003, studies from samples of wild animals sold as food in the local market in Guangdong, China, found the SARS coronavirus could be isolated from palm civets (Paguma sp.), but the animals did not always show clinical signs. The preliminary conclusion was the SARS virus crossed the xenographic barrier from palm civet to humans, and more than 10,000 masked palm civets were killed in Guangdong Province. Virus was also later found in raccoon dogs (Nyctereuteus sp.), ferret badgers (Melogale spp.), and domestic cats. In 2005, two studies identified a number of SARS-like coronaviruses in Chinese bats.
Phylogenetic analysis of these viruses indicated a high probability that SARS coronavirus originated in bats and spread to humans either directly or through animals held in Chinese markets. The bats did not show any visible signs of disease, but are the likely natural reservoirs of SARS-like coronaviruses. In late 2006, scientists from the Chinese Centre for Disease Control and Prevention of Hong Kong University and the Guangzhou Centre for Disease Control and Prevention established a genetic link between the SARS coronavirus appearing in civets and humans, bearing out claims that the disease had jumped across species.
- 2009 flu pandemic
- Bird flu
- MERS-CoV – Coronavirus discovered in June 2012 in Saudi Arabia
- Health crisis
- Jiang Yanyong
- Public health in the People's Republic of China
- SARS conspiracy theory
- Progress of the SARS outbreak
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- War Stories, Martin Enserink, Science 15 March 2013: 1264–1268. In 2003, the world successfully fought off a new disease that could have become a global catastrophe. A decade after the SARS outbreak, how much safer are we?
- SARS: Chronology of the Epidemic Martin Enserink, Science 15 March 2013: 1266–1271. In 2003, the world successfully fought off a new disease that could have become a global catastrophe. Here's what happened from the first case to the end of the epidemic.
- Understanding the Enemy, Dennis Normile, Science 15 March 2013: 1269–1273. Research sparked by the SARS outbreak increased the understanding of emerging diseases, though much remains to be learned.
|Library resources about
Severe acute respiratory syndrome (SARS)
|Wikimedia Commons has media related to SARS.|
- Vaccine Research Center Information regarding preventative vaccine research studies
- MedlinePlus: Severe Acute Respiratory Syndrome News, links and information from The United States National Library of Medicine.
- Severe Acute Respiratory Syndrome (SARS) Symptoms and treatment guidelines, travel advisory, and daily outbreak updates. From the World Health Organization (WHO).
- Severe Acute Respiratory Syndrome (SARS) Information on the international outbreak of the illness known as severe acute respiratory syndrome (SARS). Provided by the US Centers for Disease Control
- Severe Acute Respiratory Syndrome (SARS) Information on Severe Acute Respiratory Syndrome (SARS) – For Health Professionals from the Public Health Agency of Canada.
- Life in Hong Kong during SARS – a gallery of images reflecting daily life in Hong Kong during the 2003 SARS outbreak.
- What we can learn from SARS Severe Acute Respiratory Syndrome (SARS)—Lessons for Future Pandemics
- Virus Pathogen Database and Analysis Resource (ViPR): Coronaviridae
- NIOSH Topic Area: Severe Acute Respiratory Syndrome (SARS)
- NIOSH Publication: Understanding Respiratory Protection Against SARS