Lessons From the SARS Crisis – More Relevant Than Ever

Screening for severe acute respiratory syndrome in the emergency department

IntroductionDuring the 2003 severe acute respiratory syndrome (SARS) crisis, we proposed and tested a new protocol for cardiac arrest in a patient with SARS. The protocol was rapidly and effectively instituted by teamwork training using high-fidelity simulation.MethodsPhase 1 was a curriculum design of a SARS-specific cardiac arrest protocol in three steps: planning the new protocol, repeated simulations of this protocol in a classroom, and a subsequent simulation of a cardiac arrest on a hospital ward. Phase 2 was the training of 275 healthcare workers (HCWs) using the new protocol. Training involved a seminar, practice in wearing the mandatory personal protection system (PPS), and cardiac arrest simulations with subsequent debriefing.ResultsSimulation provided insights that had not been considered in earlier phases of development. For example, a single person can don a PPS worn for the SARS patient in 1 1/2 minutes. However, when multiple members of a cardiac arrest team were dressing simultaneously, the time to don the PPS increased to between 3 1/2 and 5 1/2 minutes. Errors in infection control as well as in medical management of advanced cardiac life support (ACLS) were corrected.ConclusionDuring the SARS crisis, real-time use of a high-fidelity simulator allowed the training of 275 HCWs in 2 weeks, with debriefing and error management. HCWs were required to manage the SARS cardiac arrest wearing unfamiliar equipment and following a modified ACLS protocol. The insight gained from this experience will be valuable for future infectious disease challenges in critical care.

Viral attacks on the blood supply: the impact of severe acute respiratory syndrome in Beijing.

The outbreak of severe acute respiratory syndrome (SARS) began after the index case was admitted on 1 March 2003. We profile the cases suspected to have acquired the infection in Tan Tock Seng Hospital (TTSH), focussing on major transmission foci, and also describe and discuss the impact of our outbreak control measures. Using the World Health Organization (WHO) case definitions for probable SARS adapted to the local context, we studied all cases documented to have passed through TTSH less than 10 days prior to the onset of fever. Key data were collected in liaison with clinicians and through a team of onsite epidemiologists. There were 105 secondary cases in TTSH. Healthcare staff (57.1%) formed the majority, followed by visitors (30.5%) and inpatients (12.4%). The earliest case had onset of fever on 4 March 2003, and the last case, on 5 April 2003. Eighty-nine per cent had exposures to 7 wards which had cases of SARS that were not isolated on admission. In 3 of these wards, major outbreaks resulted, each with more than 20 secondary cases. Attack rates amongst ward-based staff ranged from 0% to 32.5%. Of 13 inpatients infected, only 4 (30.8%) had been in the same room or cubicle as the index case for the ward. The outbreak of SARS at TTSH showed the challenges of dealing with an emerging infectious disease with efficient nosocomial spread. Super-spreading events and initial delays in outbreak response led to widespread dissemination of the outbreak to multiple wards.

To the Editor: Severe acute respiratory syndrome (SARS) is a recently recognized infectious disease caused by a novel human coronavirus (SARS-CoV) (1). The first case of SARS, diagnosed as communicable atypical pneumonia, occurred in Guangdong Province, China, in November 2002. Thousands of patients with SARS have been reported in over 30 countries and districts since February 2003. SARS is clinically characterized by fever, dry cough, myalgia, dyspnea, lymphopenia, and abnormal chest radiograph results (1–3). According to the World Health Organization (WHO) (4), the criteria to define a suspected case of SARS include fever (>38°C), respiratory symptoms, and possible exposure during 10 days before the onset of symptoms; a probable case is defined as a suspected case with chest radiographic findings of pneumonia and other positive evidence. Although most reported patients with SARS met the WHO criteria, we found two SARS case-patients who did not exhibit typical clinical features. Case 1 was in a 28-year-old physician. He had close contact with three SARS patients on February 1, 2003. After 10 days, he had mild myalgia and malaise with a fever of 37.3°C. He had no cough and no other symptoms. Leukocyte and lymphocyte counts were normal. The chest radiograph showed no abnormalities. He did not receive any treatment except rest at home. His symptoms disappeared after 2 days. He completely recovered and returned to work 4 days after onset of symptoms. After 12 weeks, his serum was positive for immunoglobulin (Ig) G against SARS-CoV in an indirect enzyme-linked immunosorbent assay (ELISA) with inactivated intact SARS-CoV as the coated antigen. Case 2 was in a 13-year-old boy whose mother had been confirmed to have SARS on February 4, 2003. Fever developed in the boy 20 days after his mother’s onset of the disease. He did not come into contact with other confirmed SARS patients during this period. He had a mild headache and diarrhea with a fever from 37.2°C to 37.8°C for 3 days. No other symptoms and signs developed, and a chest radiograph showed no abnormalities. He completely recovered after 5 days. After 12 weeks, his serum was positive for IgG against SARS-CoV, detected with an ELISA. In both case-patients, SARS had been initially excluded in spite of their close contacts with SARS patients because their symptoms could be explained as a common cold, and no specific diagnostic approaches were considered when they were sick since the causative agent of SARS was not identified until March 2003 (5). However, their serum specimens were positive for IgG against SARS-CoV by ELISA. Those results strongly indicate that both patients had been infected with SARS-CoV, although their signs and symptoms did not meet the criteria for the SARS case definition. Mild SARS-CoV infection may not easily be defined clinically, and such patients may potentially spread the disease if they are not isolated.

Confidence in controlling a SARS outbreak: Experiences of public health nurses in managing home quarantine measures in Taiwan

Peripartum use of Extracorporeal Membrane Oxygenation (ECMO) in a Patient Suffering from COVID-19 Severe Acute Respiratory Distress Syndrome (ARDS): A Case Report

BackgroundCoronavirus disease 2019 (COVID‐19) is a rapidly emerging disease classified as a pandemic by the World Health Organization (WHO). To support the WHO with their recommendations on quarantine, we conducted a rapid review on the effectiveness of quarantine during severe coronavirus outbreaks.ObjectivesTo assess the effects of quarantine (alone or in combination with other measures) of individuals who had contact with confirmed or suspected cases of COVID‐19, who travelled from countries with a declared outbreak, or who live in regions with high disease transmission.Search methodsAn information specialist searched the Cochrane COVID‐19 Study Register, and updated the search in PubMed, Ovid MEDLINE, WHO Global Index Medicus, Embase, and CINAHL on 23 June 2020.Selection criteriaCohort studies, case‐control studies, time series, interrupted time series, case series, and mathematical modelling studies that assessed the effect of any type of quarantine to control COVID‐19. We also included studies on SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome) as indirect evidence for the current coronavirus outbreak.Data collection and analysisTwo review authors independently screened abstracts and titles in duplicate. Two review authors then independently screened all potentially relevant full‐text publications. One review author extracted data, assessed the risk of bias and assessed the certainty of evidence with GRADE and a second review author checked the assessment. We used three different tools to assess risk of bias, depending on the study design: ROBINS‐I for non‐randomised studies of interventions, a tool provided by Cochrane Childhood Cancer for non‐randomised, non‐controlled studies, and recommendations from the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) for modelling studies. We rated the certainty of evidence for the four primary outcomes: incidence, onward transmission, mortality, and costs.Main resultsWe included 51 studies; 4 observational studies and 28 modelling studies on COVID‐19, one observational and one modelling study on MERS, three observational and 11 modelling studies on SARS, and three modelling studies on SARS and other infectious diseases. Because of the diverse methods of measurement and analysis across the outcomes of interest, we could not conduct a meta‐analysis and undertook a narrative synthesis. We judged risk of bias to be moderate for 2/3 non‐randomized studies of interventions (NRSIs) and serious for 1/3 NRSI. We rated risk of bias moderate for 4/5 non‐controlled cohort studies, and serious for 1/5. We rated modelling studies as having no concerns for 13 studies, moderate concerns for 17 studies and major concerns for 13 studies.Quarantine for individuals who were in contact with a confirmed/suspected COVID‐19 case in comparison to no quarantineModelling studies consistently reported a benefit of the simulated quarantine measures, for example, quarantine of people exposed to confirmed or suspected cases may have averted 44% to 96% of incident cases and 31% to 76% of deaths compared to no measures based on different scenarios (incident cases: 6 modelling studies on COVID‐19, 1 on SARS; mortality: 2 modelling studies on COVID‐19, 1 on SARS, low‐certainty evidence). Studies also indicated that there may be a reduction in the basic reproduction number ranging from 37% to 88% due to the implementation of quarantine (5 modelling studies on COVID‐19, low‐certainty evidence). Very low‐certainty evidence suggests that the earlier quarantine measures are implemented, the greater the cost savings may be (2 modelling studies on SARS).Quarantine in combination with other measures to contain COVID‐19 in comparison to other measures without quarantine or no measuresWhen the models combined quarantine with other prevention and control measures, such as school closures, travel restrictions and social distancing, the models demonstrated that there may be a larger effect on the reduction of new cases, transmissions and deaths than measures without quarantine or no interventions (incident cases: 9 modelling studies on COVID‐19; onward transmission: 5 modelling studies on COVID‐19; mortality: 5 modelling studies on COVID‐19, low‐certainty evidence). Studies on SARS and MERS were consistent with findings from the studies on COVID‐19.Quarantine for individuals travelling from a country with a declared COVID‐19 outbreak compared to no quarantineVery low‐certainty evidence indicated that the effect of quarantine of travellers from a country with a declared outbreak on reducing incidence and deaths may be small for SARS, but might be larger for COVID‐19 (2 observational studies on COVID‐19 and 2 observational studies on SARS).Authors' conclusionsThe current evidence is limited because most studies on COVID‐19 are mathematical modelling studies that make different assumptions on important model parameters. Findings consistently indicate that quarantine is important in reducing incidence and mortality during the COVID‐19 pandemic, although there is uncertainty over the magnitude of the effect. Early implementation of quarantine and combining quarantine with other public health measures is important to ensure effectiveness. In order to maintain the best possible balance of measures, decision makers must constantly monitor the outbreak and the impact of the measures implemented.This review was originally commissioned by the WHO and supported by Danube‐University‐Krems. The update was self‐initiated by the review authors.

COVID-19 and Gastrointestinal Tract Symptoms: Recognition, Containment, and Learning From the Past

The diagnosis of severe acute respiratory syndrome (SARS) in surgical patients can potentially be missed based on current World Health Organization (WHO) case definitions. We report a retrospective case series of 10 surgical inpatients diagnosed with SARS following an outbreak in the surgical wards. Patients were included if they fulfilled the WHO case definition of probable SARS, had an active surgical problem and were admitted to the surgical wards during the outbreak period. Clinical histories, laboratory investigations and radiological findings were reviewed and analyzed. The mean age of the cohort was 57.6 years (range: 38-78 years). Nine patients had concomitant medical conditions. Three patients were in the early postoperative period, while the remaining seven were admitted for surgical related infections. All patients presented with fever, but only eight had accompanying respiratory symptoms. Lymphopenia and raised lactate dehydrogenase (LDH) was seen in seven patients. Eight patients had positive bacterial cultures. The primary abnormality on chest radiograph was air-space opacification. Rapid progression of radiological changes was seen in seven patients. Mortality rate for our cohort is 20%. The diagnosis of SARS in surgical patients differs from that previously described in normal patients. An apparent cause of fever and positive blood cultures cannot exclude a diagnosis of SARS. The current WHO case definition could result in delayed or even missed diagnosis. Early isolation of febrile patients with a positive contact history must be undertaken, even in the face of another identifiable cause.

Singapore was one of 29 countries worldwide affected by severe acute respiratory syndrome (SARS) in 2003. There were 238 cases identified during the outbreak. We performed a retrospective analysis of the clinical and laboratory data of 234 patients admitted to Tan Tock Seng Hospital and Singapore General Hospital. The mean age of patients was 21 years, 31.6% of patients were males and 41.8% were healthcare workers. At presentation, the common symptoms were fever, myalgia, cough and headache; rhinorrhoea was uncommon. On admission, 21% had leukopenia, 18% had thrombocytopaenia, 29% had hyponatraemia, 31% had hypokalaemia, 21% had transaminitis. Polymerase chain reaction (PCR) testing of respiratory and stool samples provided the best yield at the end of the first week of illness. Thirty-two patients were initially not recognised as probable SARS and were reclassified when the serology test results were available. The chief reasons for not identifying these patients early were persistently normal chest X-rays (68.8%), very mild presentation (43.8%) and the presence of a concomitant illness (12.5%). Overall, 12% of the patients were probable SARS with atypical presentations. Overall mortality was 11.8%. Patients infected with the SARS coronavirus had a wide clinical presentation with non-specific symptoms.

Urogenital System Damaging Manifestations of 3 Human Infected Coronaviruses.

Corona viruses (CoVs) are well-covered RNA viruses that cause enteric and respiratory infections in humans and animals. Many human CoVs have recently gained global interest because of their lethal power and high contagious power. SARS-CoV-2, or COVID-19, is a pathogenic coV that first appeared in Wuhan, China.
 Corona virus Disease 2019 (COVID-19) created by SARS-CoV-2, has been declared as pandemic by the World Health Organization since March 11, 2020. The epidemic started in Wuhan and spread rapidly around the world. Corona virus is facing a major epidemic: Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). SARS-CoV-2 is a virus closely related to SARS.
 Corona virus (COVID-19) is caused by SARS-CoV-2 VIRUS, a complex clinical disorder characterized by severe pneumonia and acute respiratory stress syndrome. Serious and neurological disorders, such as encephalitis, coma, fever, epilepsy, and Guillain-Barré syndrome, are more common in cases of COVID-19. In addition, chronic autoimmune and neurodegenerative diseases may occur in SARS-CoV-2 immunopathology and colonization of intestinal and central nervous system, as well as systemic inflammatory response during COVID-19. Parkinson's disease is a common neurodegenerative condition that causes the development of motor and non-motor symptoms.

To provide an overview of the severe acute respiratory syndrome (SARS) outbreak in Toronto, Ontario, which experienced the largest outbreak outside Asia, and to review what has been learned during the past year. MEDLINE search of all studies related to SARS, including review of the Centers for Disease Control and Prevention, World Health Organization (WHO), and Health Canada Web sites. During the SARS outbreak in Toronto, 438 people had been diagnosed as having suspected or probable SARS and 44 people died. Elderly people and those with comorbid illnesses were at greatest risk of complications or death. Transmission was via direct contact with respiratory secretions. The use of gloves, gowns, N95 masks, and eye protection was effective in preventing transmission. No transmission occurred before symptom onset or after recovery. Serologic tests suggest that antibodies may not appear until 28 days after illness onset. Molecular tests give their greatest yield during the second week of illness. The value of ribavirin treatment remains questionable. The combination of interferon plus corticosteroids appears to be better than corticosteroids alone. Postmortem examination revealed pulmonary edema and evidence of diffuse alveolar damage. Very few morphological changes were noted in other organs despite the presence of viral RNA as detected by polymerase chain reaction. On July 5, 2003, the WHO declared that the SARS outbreak was over. Since then, new cases of SARS have been reported in Asia. With global travel, the disease can rapidly spread throughout the world. Therefore, we must remain vigilant to prevent another pandemic.

This study contributes to the existing literature by examining whether the SARS (severe acute respiratory syndrome) health scares had a permanent or transitory effect on tourist arrivals in a transition economy – Cambodia. The findings, which are based on unit root tests with an unknown level shift proposed by Lanne et al (2002) and Saikkonen and Lütkepohl (2002), show that visitor arrivals from Cambodia's major source markets are stationary. This implies that the SARS crisis had a transitory effect on Cambodia.