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- Abhijit Kambalapally
- Nimesh Das
- Ginny Joshi
- Ridwan Rahman
- Eshan Shah
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What is SARS?
Origins of SARS
SARS Timeline
Countries Affected
SARS Cases
Cause/ Effect
Symptoms
Social Impact
Ethical Impact
10. Economic Impact
11. Medical Impact
12. WHO
13. Quarantine
14. Disease Control
15. Treatment
16. Diagnostic Tests
17. Vaccine Found
18. Preventive Measures
“This syndrome, SARS, is now a
worldwide health threat, ... The world
needs to work together to find its cause,
cure the sick and stop its spread.”
- Gro Harlem Brundtland
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The acronym “Sars” stands for, Severe Acute
Respiratory Syndrome
Sars is a severe respiratory illness caused by a specific
type of corona virus (SARS-CoV)
Another form of pneumonia, except more lethal
In the 2003 outbreak, several countries in Asia, Europe,
North and South America were plagued by Sars
In total, 8098 people were infected, of which 774 died
251 cases in Toronto, of which 44 died
• The outbreak was contained by 2004
• Sars does not have a definite healing period;
depends from person to person
• older people, patients with weak immune systems
and STD patients are targeted more frequently by
the disease
Coronavirus
• A type of virus that usually causes minor
respiratory problems in humans but severe
diseases in animals (neurologic, gastrointestinal,
liver, respiratory)
• As a result, it is believed that animals have
caused the severe SARS-CoV virus among
humans; real cause is still under investigation
• incubation period is 2-7 days although infection
may take up to 10+ days
13 Laboratories from 10 nations including Hong Kong, U.S and
Germany confirmed the Coronavirus in March 2003
Methods used to identify coronavirus:
isolation on cell culture
electron microscopy
polymerase chain reaction
microarray technology
immunofluorescent antibody tests (Peiris, Drosten, Kseizaek)
Proofs
 Pathogen found
 Isolated from host and grown in pure culture
 Inoculation of of cynomolgus macaques with Vero-cell
cultured virus (caused interstitial pneumonia akin to SARS
coronavirus; isolated from nose/throat of monkeys)
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Canadian researchers from Michael Smith Genome
Sciences Centre in Vancounver, B.C. and National
Microbiology Lab in Winnipeg, Manitoba uncovered the
genome sequence
Related to murine, bovine, porcine and human
coronavirus in the group HcoV – 229E
Since it is different, there’s another group (Marra)
associated with the SARS virus
Sequence analysis reveals that it originated from an
animal capable of infecting humans or crossing the
species barrier
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Through negative-stain transmission electron
microscopy and cell culture supernatans, the
coronavirus was determined to be 60 – 130 nm
Thin-section electron microscopy was used to examine
particles of virus within cytoplasmic membrane-bound
vacuoles and endoplasmic reticulum
Large Clusters of extracellular particles are present
along surface of plasma membrane
Sars-Cov genome has 5 reading frames (ORFs) that encode replicase
polyprotein; spike (S), envelope (E), membrane (M) glycoproteins;
and nucleocapsid protein (N)
S protein
 binds to species-specific host cell receptors
 help fusion of viral envelope and cellular membrane
 virulence factor
 viral antigen that extracts the neutralizing antibody
M protein
 major component of virion envelope
 determinant of virion morphogenesis (uses S proteins to make
virions)
 selects genome for incorporation into virion
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SARS-CoV detected in lungs and kidneys,
bronchoalveolar lavage specimen, sputum (100 million
molecules per millilitre), upper respiratory tract swab,
aspirate and wash specimens
Detected in nasopharyngeal aspirates (32%) 3.2 days
after onset of illness, and 68% in day 14
Stool samples detected Viral RNA at 97% after 2 weeks;
42% of urin samples were positive for viral RNA
Detected in plasma
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1st case of Sars: reported in November 2002,
Shunde, Foshan (Guadong Province) China
Victim: a farmer; treated in Mckay Dennis
Hospital
Result: Patient died and diagnosis on the cause
was left unfinished
Chinese government worked hard to prevent
word about outbreak
Once WHO reach epidemic proportions
Chinese forced to admit
 27th
November 2002 - Canada’s Global Public Health Intelligence
Network (GPHIN), an electronic warning system, part of WHO’s
Global Outbreak and Alert Response Network (GOARN)
discovered reports about a “flu” epidemic in China through
internet screening and notified WHO
 5th and 11th December - WHO requested intelligence from the
Chinese government
 In the process, weakness and holes in the system were highlighted
as they were highly dependent on the Chinese government to
respond
 On 21 January, 2003 – first English report outlining the outbreak
was disclosed; limited to only 1 other language (formed as an
easily-avoidable barrier)
 March 2003 – WHO released name, definition and activated a
global outbreak response network team to raise awareness of Sars
 When containment measures were finally taken, 500 deaths and
2000 cases had already been encountered
 America’s Centre for Disease Control and Prevention took
initiative and the disease soon became an international concern
Hong Kong, China
Thailand
Toronto, Ontario
Singapore
Vietnam
Taiwan
Vietnam
 February 2003 – An American businessman flying from China to
Singapore reported having symptoms of pneumonia.
 Plane stopped at Hanoi, Vietnam and the victim died in the Hospital
of Hanoi
 Shortly after, medical staff who treated the businessman became
diagnosed with SARS
 Carlo Urbani, an Italian doctor notified the Vietnamese government
but became infected by SARS himself
Hong Kong
 Another trail had been traced back to a doctor from the 9th floor of
Metropole Hotel in Kowloon Peninsula, who infected 16 hotel visitors
 Visitors travelled to Singapore, Taiwan, Canada, Vietnam, spreading
SARS there
 Other places the disease spread – Toronto, Ottawa, San Francisco,
Ulan Bator, Manila, Hanoi, Hong Kong, Jilin, Hebei, Hubei, Shaanxi,
Jiangsu, Shanxi, Tianjin, Inner Mongolia
Amoy Gardens
• A high concentration of cases were reported in a housing
Estate called Amoy Gardens and said to be caused by
poor sewage systems
Beijing Military System
• Pressure from citizens prompted an investigation by
Chinese government in this location
• Problems included: decentralization, red tape, inadequate
communication, basically revealing deteriorating health
care system within the nation
Red Tape - A term used to describe explicit rigidness within
a bureaucratic system; interfered with containment of Sars
• On 16 April 2003, the World Health Organization issued a
press release stating that a coronavirus identified by a number
of laboratories was the official cause of SARS
• Coronaviruses are species in the genera of animal virus
belonging to the subfamily Coronavirinae in the family
Coronaviridae
• They are positive-strand, enveloped RNA viruses that are
important pathogens of mammals and birds
• many kinds of coronavirus, some of which cause the common
cold
• Experts say main way it spreads is through close contact with
an infected person, spread through exhaled droplets and body
secretions.
• can come into contact with this when an affected person
coughs or sneezes
• experts also say SARS may also be spread when fecal matter
containing the virus is ingested (ex. due to poor sewage
treatment, contaminated food or water)
• Virus was also later found in raccoon dogs, ferret badgers and
domestic cats, and mainly the masked palm civet
• Outbreak in Guangdong started when humans infected as they
raised and slaughtered wild animals for food
• Spread when people ate contaminate civets
• Civets considered gourmet delicacy in China
• Most if not all cases of SARS in Canada during the 2003
outbreak occurred in people who had recently travelled to Asia,
health care workers who had cared for SARS patients and close
family member of SARS patients
• Long term effects on survivors - effects on pulmonary
function, exercise capacity, and health-related quality of
life(according to a study of 86 survivors of SARS at the
Chinese University of Hong Kong, in Hong Kong, PRC)
• SARS also brought trauma to patients and their families, may
require psychological, social and financial support
• SARS has social impacts on countries who had the disease
• combined with other factors, SARS heavily affected tourism
industry; particularly destinations which registered highest
numbers of victims
• The incubation period ranges from 2 to 10 days. This
means that once someone has been exposed, it can take
anywhere from 2 to 10 days for symptoms to occur
• The initial indication of infection is a fever of 100.4 degrees
Fahrenheit or more (38 degrees Celsius or more)
• A dry, unproductive cough develops after 3 to 7 days
• Other symptoms may include headaches, an overall feeling
of discomfort, and body aches
• Dry cough, chills and shivering, muscle aches and
breathing difficulties
• About 10 percent to 20 percent of patients have diarrhea
• After 2 to 7 days, SARS patients may develop a dry cough
• Most patients develop pneumonia
• The most common symptom however appears to be a fever
above 38 °C (100.4 °F)
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tends to occur in large epidemics with a magnitude like
SARS, is a developed social stigma toward the community or
region from which it originated
 This led to ignorant individuals to ostracize members of the
oriental community in fear of contracting the disease from them
 This is reflected in the fall in business for Chinese enterprises,
particularly restaurants.
 Hatred toward the Chinese community an also stem from death of
close relation due to SARS, as a means of blaming the death of
them
 Globalization and it’s link to social contexts played a factor in
SARS as it socially deterred individuals from actively experiencing
foreign cultures or environments, severely impacting tourism
 As a result of the growing web of interconnections due to
globalization, microbes have an easier ride than ever to cross
countries, and span continents
• For example, consider that in the Middle Ages, it took three years
for the plague to spread from Asia to the western reaches of
Europe. In perspective, the SARS virus, crossed from Hong
Kong to Toronto in about 15 hours
• A socio-ethical issue also refers to the privacy of one’s
information versus the public need to know
• The social impact of releasing confidential information for the
betterment and safety of society can be detrimental on the
individual it pertains to
• For example, the name of the woman who was identified as
accidentally bringing SARS to Canada is made public, Kwan Suichu. Upon her return home to Toronto, she passes it to her
family, starting a chain of contamination. She dies at home, but
her son goes to hospital for treatment of fever and a cough,
beginning a series of infections in the city.
• Socially, this would lead to the spread of stigma against those of
Chinese origin, and further ostracise and isolate the son in social
context
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The most severe ethical issues that arose from the SARS
outbreak concern quarantine and health care professionals
Quarantine: Individual freedom vs. Protection of public at
large
Considering SARS’ highly contagious nature, thousands in
Toronto were placed in quarantine, in order to protect millions
of people in the city and around the world from possible
exposure to a deadly disease
However this was often also considered an infringement on
one’s individual freedoms, thus the issue’s ethical constraints
Officials should then be forced to consider whether the
interest in protection of public health trumps the freedoms of
an individual whom unintentionally poses a potential ‘threat’
to society
One must determine whether they value the honour of
upholding an institutionally sound social freedom at the cost
of affecting the safety of the health of many, including those
outside our political borders
• An ethical solution lies in adequately informing the individual of
why there rights are being overridden and the degree to which
they threaten the general health of the public, and to assist in
reducing the impact of any collateral damages the quarantine may
cause
• Health care professionals: Public obligation vs. fear of one’s
personal safety
• Society is aware of the health care sector’s duty to provide for the
sick, considering virtue ethics (to do good for others) and the
professional oath they are obliged to carry out
• However, doing so during an epidemic such as SARS puts them at
risk of contracting the disease and making them prone to easily
succumb to it’s effects
• Thus to what extent should health care professionals be held in
their line of duty as they balance the question to avoid health risks
to themselves and their families, opposed by their obligation and
need to maintain a salary on the line
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public example of the sacrifice
by health care worker was
untimely and tragic death of Dr.
Carlo Urbani, who was infected
in Vietnam.
A solution to this would lie in
institutions equally
reciprocating what the health
care workers are investing into
the job at times like SARS.
Includes: providing information
for staff so they can fully
understand the risks, and
policies supporting safety
practices
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was significant collateral damage due to the waiting times,
and constraints on hospital schedules
 This was often directed towards patients who did not have SARS.
Many people with other serious conditions had surgeries cancelled
because some hospitals were considered contaminated areas, and
some of these people died
 At the University Health Network alone, which includes Toronto
General, Toronto Western and Princess Margaret hospitals, 1,050
surgical procedures were cancelled because of SARS
 Considering the social impacts and the build up of stigmatism
toward China, there could also be severe impacts on trade
relations and GDP for both China and it’s trading partners
 This could stem from fear of foreign products (as globalization has
increased the spread rate of disease) and resulting embargos
• There was a decline in the tourism industry in the years SARS
was active, where the industry lost more than $500 million and
28,000 jobs [Burns research]
• also severe repercussions specifically for owners of oriental
restaurants in the GTA area, during the height of the SARS
hype as Ontario total restaurant receipts declined 1.6% in April
2003 [CRFA]
• However in a country as well developed as Canada with a
market economy, it has been concluded that the long term
economical impacts from a pandemic such as SARS are
relatively low
• Eventually people adapt to the shock and shift spending across
different sectors
• One also found that spending was spread across time which
allowed the economy as a whole to recover quickly. While
most sectors rebound rapidly, others, such as previously
mentioned with tourism, did suffer more lasting effects
• since outbreak it’s etiology, transmission route has received closer
research attention
• Toronto SARS crisis demonstrated, the current practice of housing
large numbers of sick admitted patients for prolonged times in
open, densely-populated EDs (Emergency Departments) is a
potential public health hazard.
• lack of long-term and acute-care hospital beds led to high hospital
occupancy rates and cohosting of admitted patients in ED
stretchers, holding areas or hallways
• This impedes ED productivity, creates crowded waiting rooms and
long care delays for patients, delays ambulance unloading, and
spawns ambulance diversions and delayed ambulance responses.
• overcrowding prevents appropriate application of infection control
safety measures, increasing the likelihood of infectious disease
transmission as it did in the Toronto SARS outbreak.
• Infection control procedures introduced during the SARS epidemic
• overcrowding prevents appropriate application of infection
control safety measures, increasing the likelihood of infectious
disease transmission as it did in the Toronto SARS outbreak.
• Infection control procedures introduced during the SARS
epidemic
• Canada’s SARS outbreak showed how the ED has been
deteriorating thus its need for urgent action
• 50% attack rates of health- care workers
• Health-care workers given gloves, surgical masks (N95), eye
protection, gowns ands told to follow scruopulous hand hygiene
• A study found that nurses most affected by outbreak,
experiencing (to a greater degree than doctors, administrators or
other hospital staff) symptoms such as trouble with sleep,
difficulty making decisions and loss of confidence
• A lot of stress was put on the Emergnecy Departments as well
• WHO now created guidelines for alert, verification, and public
health management of SARS on its website
• SARS shows willingness of international community to form
united front against shared threat
• The first measure taken by the
World Health Organization or
WHO for the prevention of
SARS was in March, 2003.
• WHO set up a network for the
doctors and researchers
dealing with SARS.
• consisted of a secure
website where doctors and
researchers could discuss,
study chest x-rays of the
patents affected by SARS
and was done through
teleconferencing.
• The initial spread of SARS could not be
stopped but attempts were made to
prevent from further infection through the
use of quarantine.
• Quarantine is done to control the spread
of a dangerous disease through complete
isolation of the person.
• 1200 people were quarantined in Hong
Kong, 977 in Singapore and 1147 in
Taiwan. Even Canada put thousands of
people of under quarantine.
• To stop the virus from spreading schools
were also closed in Singapore and Hong
Kong for a 10 days.
• On 27 March 2003, the WHO
recommended the screening of airline
passengers for the symptoms of SARS.
• Singapore’s Ministry of
Health implemented the
Infectious Diseases Act on
March 24.
• According to it, home
quarantined was imposed
on all people who have
come in contact with SARS
patients.
• Telephone surveillance and electronic picture camera,
placed outside the door of the contact, were used to check
upon them. Security officers from CISCO and a
Singaporean auxiliary police force helped serve the
quarantine orders to homes.
On 24 April, the Singaporean government made amendments to the
Infectious Diseases Act and included penalties for the violation. These
amendments included:
1.
2.
Suspected persons of the infectious disease were to be
brought to the treatment centers. They were also prohibited
from going to public places.
Access was restricted to certain designated contaminated
areas.
3.
Offenders were to be tagged using electronic wrist tags for
breaking the home quarantine and fines were also imposed
on them.
4.
Anyone caught lying to the health officials about their travel
to SARS-affected areas were subject to prosecution.
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It was found that antibiotics were ineffective since SARS is a
viral disease.
Antipyretics, supplemental oxygen and ventilatory support were
helpful in reducing the infection but not treating it.
Suspected cases of SARS were isolated and kept in negative
pressure rooms. Strict nursing precautions were taken for any
necessary contact between patients.
Initially, there was support for steroids and antiviral drug ribarivin
but since there was no published evidence this treatment was
dropped.
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Treating SARS is difficult because by the time the symptoms
in a patient appear, the infection would have spread and
would have already greatly damaged the lungs.
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Patients are given oxygen to help relieve their breathing
difficulties, and physiotherapy is used to clear the fluid in the
lungs. Patients may be even put on a ventilator in severe
cases.
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Antibiotics may be given but, as mentioned earlier, they are
not to treat the virus, they are used to prevent any further
infection by opportunistic bacteria.
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Antiviral medicines can be used to block the replication of
the virus in side lung cells. However, there was little benefit
in using this treatment.
ELISA – enzyme-linked immunosorbent assay
 Detects antibodies to SARS after 21 days
Immunofluorescence Assay
 Detects antibodies after 10 days
 Time-consuming
 Rigorous
 Requires highly qualified operator, and a specialized microscope
Polymerase Chain reaction
 Detects SARS in blood, sputum, tissue samples, stools
 Insensitive (probability of having SARS remains even after patients are
tested negative)
• Researchers started testing all antiviral
treatments of other diseases on the
SARS causing coronovirus.
Also, it was known that serious damage in
SARS was caused due cytokine storm (occurs when the
body’s immune system overreacts to the virus).
 Finally, in December 2004, a group of Chinese researchers
had produced a SARS vaccine. Out of the 36 volunteers it
was tested on, 24 developed antibodies against the virus.
 how successful this vaccine would be remains unknown.
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Washing hands frequently: soaps
or alcohol based hand rub
containing at least 60% of alcohol
prevent the bacteria and viruses
getting onto the skin.
Wearing infection controlled
masks: WHO recommends
standard masks or the N5
masks which are more
effective than the surgical
masks. These masks will
protect you from 95% of the
micro-organisms in the air.
Wearing disposable gloves, gowns, eye
protection: these minimize the opportunity for
the virus to gain internal access of the body by
contact.
Avoid skin contact with the patients
and family members, avoid touching
your eyes, nose or mouth, avoid
sharing food with those infected.
Disinfect surfaces: By using a household
disinfectant or diluted bleach, clean and
disinfect areas where patients have been
there, including furniture, toilet facilities etc.
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