Spread of SARS a month after the Metropole Hotel incident.A chest x-ray showing increased opacity in both lungs, indicative of pneumonia, in a patient with SARS."8 Steps Towards SARS Prevention", public information poster issued by the Chinese government in 2003.
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Severe acute respiratory syndrome

Severe acute respiratory syndrome, better known by its acronym SARS, is an atypical form of pneumonia. It first appeared in November 2002 in Guangdong Province of the People's Republic of China. SARS is now known to be caused by the SARS coronavirus (SARS-CoV), a novel coronavirus. SARS has a mortality rate of around 10 percent. more...

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After the People's Republic of China suppressed news of the outbreak both internally and abroad, the disease spread rapidly, reaching neighbouring Hong Kong and Vietnam in late February 2003, and then to other countries via international travellers. The last case in this outbreak occurred in June 2003. There were a total of 8437 cases of disease, with 813 deaths.

In May 2005, the New York Times reported that "not a single case of severe acute respiratory syndrome has been reported this year or in late 2004. It is the first winter without a case since the initial outbreak in late 2002. In addition, the epidemic strain of SARS that caused at least 813 deaths worldwide by June of 2003 has not been seen outside a laboratory since then."

For a timeline of the SARS outbreak, see Progress of the SARS outbreak.

Outbreak in the People's Republic of China

The virus appears to have originated in Guangdong province in November 2002, and despite taking some action to control the epidemic, the People's Republic of China did not inform the World Health Organisation (WHO) of the outbreak until February 2003, restricting coverage of the epidemic in order to preserve face and public confidence. This lack of openness caused the PRC to take the blame for delaying the international effort against the epidemic. The PRC has since officially apologized for early slowness in dealing with the SARS epidemic.

In early April, there appeared to be a change in official policy when SARS began to receive a much greater prominence in the official media. However, it was also in early April that accusations emerged regarding the undercounting of cases in Beijing military hospitals. After intense pressure, PRC officials allowed international officials to investigate the situation there. This has revealed problems plaguing the aging mainland Chinese healthcare system, including increasing decentralization, red tape, and inadequate communication.

In late April, revelations occurred as the PRC government admitted to underreporting the number of cases due to the problems inherent in the healthcare system. Dr. Jiang Yanyong exposed the coverup that was occurring in China, at great personal risk. He reported that there were more SARS patients in his hospital alone than were being reported in all of China. A number of PRC officials were fired from their posts, including the health minister and mayor of Beijing, and systems were set up to improve reporting and control in the SARS crisis. Since then, the PRC has taken a much more active and transparent role in combatting the SARS epidemic.

Spread to other countries

The epidemic reached public spotlight in February 2003, when an American businessman travelling from China came down with pneumonia-like symptoms while on a flight to Singapore. The plane had to stop at Hanoi, Vietnam, where the victim died in a hospital. Several of the doctors and nurses who had attempted to treat him soon came down with the same disease despite basic hospital procedures. Several of them died. The virulence of the symptoms and the infection of hospital staff alarmed global health authorities fearful of another emergent pneumonia epidemic. On March 12, 2003, the WHO issued a global alert, followed by a health alert by the United States Centers for Disease Control and Prevention (CDC).

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Diagnosing severe acute respiratory syndrome
From American Family Physician, 6/15/05 by Richard Sadovsky

The early diagnosis of suspected severe acute respiratory syndrome (SARS) is essential to allow for early isolation and treatment. The case definition developed by the World Health Organization (WHO) defines a suspect case as a patient with high fever, cough or breathing difficulty, and direct exposure or travel through a SARS-affected region within 10 days before symptom onset. A probable case meets the criteria for a suspect case and has additional chest radiographic evidence of infiltrates or laboratory results positive for SARS coronavirus. The use of these criteria alone, however, may result in underdiagnosis. Leung and associates developed a clinical prediction rule for diagnosis to identify SARS in the emergency department during an outbreak.

Clinical and laboratory data from patients presenting to the SARS triage clinics of two large hospitals in Hong Kong were abstracted for analysis by the authors. Using cohorts of patients treated during SARS outbreaks with a SARS diagnosis confirmed by laboratory testing, a two-step prediction rule was derived. Step one identified the subgroup of patients likely to have SARS and need further evaluation, and step two involved analyzing this high-risk population for radiologic and laboratory characteristics.

In step one, age in years and contact history were associated with a SARS diagnosis, as was the presence of three symptoms: fever, myalgia, and malaise. The absence of sputum production, abdominal pain, sore throat, and rhinorrhea also were independently associated with a SARS diagnosis.

In step two, four laboratory or radiographic findings were associated with a SARS diagnosis, including chest radiograph, lymphocyte count, neutrophil count, and platelet count. After inclusion of step two investigations, several of the historical and physical finding factors no longer achieved statistical significance.

The scoring system used to quantify the association of certain risk factors with SARS are listed in the accompanying table. The higher the score beyond 8, the higher the risk of SARS, with a risk score of 19 or greater representing the highest-risk group. Using this prediction rule achieved a sensitivity of 0.90 and a specificity of 0.62. An internal validation exercise showed good results.

The authors conclude that this prediction rule for SARS risk would allow rapid triage of patients. Patients designated as low risk could be sent home with daily follow-up for the four- to five-day incubation period that precedes the severe clinical syndrome. Patients whose risk score exceeds 8 should be admitted with room allocation guided by the total risk score. Prospective validation of this clinical prediction rule is needed if SARS returns.

RICHARD SADOVSKY, M.D.

Leung GM, et al. A clinical prediction rule for diagnosing severe acute respiratory syndrome in the emergency department. Ann Intern Med 2004;141:333-42.

EDITOR'S NOTE: Epidemiologic studies of severe acute respiratory syndrome coronavirus hint that a repeat epidemic from infected animals or laboratory-stored specimens is possible. In an accompanying editorial, Jernigan and associates (1) note the need for better diagnostic techniques in the first few days of illness. The clinical prediction rule described above may be useful, but external validation is essential because of epidemiologic variables that have been occurring among affected groups in different settings and geographic regions. It also is unclear that a prediction rule derived during an epidemic will be helpful in sporadic cases noted between outbreaks.

REFERENCE

(1.) Jernigan JA, Helfand RF, Parashar UD. Accurate clinical prediction of severe acute respiratory syndrome: are we there yet? Ann Intern Med 2004;141:396-8.

COPYRIGHT 2005 American Academy of Family Physicians
COPYRIGHT 2005 Gale Group

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