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Severe Acute Respiratory Syndrome (SARS) Viral respiratory illness caused by the SARS-associated coronavirus (SARSCoV). Coronaviruses: Infectious Diseases: SARS – Cause infection in humans and animals. – Tend to cause respiratory tract infections in humans. – Have been linked with gastroenteritis. Pacific Emergency Management, Preparedness, and Response Information Network and Training Services (Pacific EMPRINTS) SARS-CoV may be a mutated form of a coronavirus found in an animal that has contact with humans. SARS-CoV’s reservoir is unknown, although recent research indicates that the coronavirus that infects humans may have originated in bats. University of Hawaii Department of Anthropology Subject Matter Expert: Alan Katz, MD, MPH O PY Pacific EMPRINTS The SARS Coronavirus (by electron microscopy, x1000). www.cdc.gov/ncidod/sars/ 2003 SARS Outbreak SARS CoV Transmission O Transmission electron micrograph of coronavirus OC43. The coronavirus is now recognized as the etiologic agent of the 2003 SARS outbreak. Photo courtesy CDC / Dr. Erskine Palmer. D O Approximately 8,000 people worldwide became sick with SARS (eight people in the U.S. had laboratory-confirmed SARS-CoV infection). Approximately 800 SARS deaths; case-fatality rate approximately 10%. T North America South America Europe Asia N – – – – Via mucous membrane contact with infectious droplets or fomites. Spread by coughing and sneezing. Travels approximately 3 feet in expelled droplets. Survives up to 2 days at room temperature, and up to 4 days in stool. Maximal virus excretion occurs at about 10 days in the respiratory tract, and at about thirteen days in stool. C February 2003 – First reported in food handlers in Southern China. Spread to more than two dozen countries, including: Risk Factors Household or other close contact with an infected person. Healthcare settings: – Twenty-one percent of global SARS cases have been found in healthcare workers.1 Air travel is only associated with a slightly increased risk. 1 Incubation Patients usually become ill within 2-10 days; mean incubation period of 4-6 days. Other coronaviruses have the ability to remain in incubation for much longer, suggesting that some infected persons carry the virus for longer than the WHO’s current projections. Shirley Chan, H. Jonathan Chong, Tevis Howard, Sarah Kimball, Michael Soule. SARS-CoV Epidemiology. Bio 160: Development of Vaccines to Infectious Diseases. Brown University, Providence, Rhode Island. April 2004. These materials may not be used or distributed in part or in entirety without written permission from Pacific EMPRINTS. 1 Diagnosis SARS Criteria Clinical Criteria: Early clinical recognition of SARS still relies on a combination of clinical and epidemiologic features.1 Most patients with SARS: – Moderate respiratory illness: Temperature of >100.4° F (>38° C), and one or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, or hypoxia). – Severe respiratory illness: Temperature of >100.4° F (>38° C), and one or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, or hypoxia), and: radiographic evidence of pneumonia, or respiratory distress syndrome, or autopsy findings consistent with pneumonia or respiratory distress syndrome without an identifiable cause. – Have a clear history of exposure either to a SARS patient or to a setting in which SARS-CoV transmission is occurring, and – Develop pneumonia. Epidemiologic Criteria: – Travel (including transit in an airport) within 10 days of onset of symptoms to an area with current or recently documented or suspected community transmission of SARS, or – Close contact within 10 days of onset of symptoms with a person known or suspected to have SARS infection. Diagnosis of SARS should be based on risk of exposure. for Disease Control and Prevention (CDC) O PY 1Centers Additional Findings Laboratory Criteria Confirmed: T – Detection of antibody to SARS-CoV in specimens obtained during acute illness or >21 days after illness onset, or – Detection of SARS-CoV RNA by RT-PCR confirmed by a second PCR assay, by using a second aliquot of the specimen and a different set of PCR primers, or – Isolation of SARS-CoV – Electron microscopy of SARS-CoV O Negative: – Absence of antibody to SARS-CoV in convalescent serum obtained >21 days after symptom onset N Undetermined: – Laboratory testing either not performed or incomplete Other laboratory findings that may be associated with SARS include: – Increases in serum alanine aminotransferase, lactate dehydrogenase, creatine kinase and prothrombin time. – Lymphocyte and platelet counts are often decreased. – Each of these changes occur in less than 50% of cases and none is specific for SARS. C CDC researchers Thomas Ksiazek D.V.M., Ph.D. (front), and Cynthia Goldsmith, M.S. (back) are working at an electron microscope. X-ray Findings: – Radiological findings in Hong Kong patients with SARS were as follows: “In the early stage of the disease, a peripheral / pleural-based opacity may be the only abnormality. This may range from ground-glass to consolidation in appearance. A particular area to review is the paraspinal region behind the heart. In our experience, this is frequently where lung lesions are detected on HRCT* in suspected SARS patients with normal radiographs. In the more advanced cases, there is widespread opacification which may be ground-glass or consolidative affecting large areas. This tends to affect the lower zones first and is not uncommonly bilateral. Calcification, cavitation, pleural effusion or lymphadenopathy are not features of this disease.” *High Resolution Computed Tomography Peiris J, et.al. Severe Acute Respiratory Syndrome, Current Concepts. NEJM (349)2431-41. 2003. Radiological appearance of recent atypical pneumonias in Hong Kong. Prepared by Drs. Anil T. Ahuja & Jeffrey K. T. Wong. Maintained by Drs. James F. Griffith & Gregory E. Antonio. 2003. (http://www.droid.cuhk.edu.hk/web/atypical_pneumonia/ atypical_pneumonia.htm) D O Photo courtesy CDC. Treatment Hospitalize and isolate suspected or probable cases of SARS . CDC recommends that patients with SARS receive the same treatment that would be used for a patient with any serious community-acquired atypical pneumonia. Lopinavir-ritonavir, in conjunction with ribavirin has been shown in clinical studies to prevent serious complications and death. Supportive care, such as supplemental oxygen, chest physiotherapy or mechanical ventilation is sometimes needed. Further testing is needed to determine an effective treatment for SARS. Isolation Isolation of symptomatic patients is an important measure in SARS, as it is likely that patients have to be symptomatic to be infectious. The spread of SARS is best prevented by isolating patients from the time of the onset of their symptoms. Expeditious isolation is difficult to achieve. 2003 SARS Epidemic: – In Singapore, the average time that patients were symptomatic before being placed in isolation was 7 days. – A prominent feature was the spread in hospital settings. The simultaneous appearance of severe respiratory infection in healthcare workers is an early tip-off to an epidemic of SARS. Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2. Supplement D: Community Containment Measures, Including Non-Hospital Isolation and Quarantine, page 29. These materials may not be used or distributed in part or in entirety without written permission from Pacific EMPRINTS. 2 Personal Prevention Future Prevention Find a vaccine to combat SARS-CoV. Develop laboratory tests for early detection. Identify potential animal reservoirs for SARS. International cooperation in monitoring potential SARS cases. The following precautions should be employed by those caring for someone with SARS, for at least 10 days after respiratory symptoms and fever are gone: – Wash hands frequently with soap and hot water, or an alcohol-based hand rub containing at least 60 percent alcohol. – Avoid touching the face and mouth. If necessary, use tissue to wipe eyes and nose. – Wear disposable gloves during contact with an infected person’s bodily fluids or feces. Immediately after contact, gloves should be removed and discarded. – Wear a surgical mask when in the same room as the infected person. Glasses or goggles may also offer some protection. – Wash the utensils, towels, bedding and clothing of the infected person with soap and hot water. – Use a household disinfectant to clean any surfaces that may have come into contact with the infected person. The SARS virus is easily killed by a chorine solution of 99 parts water to 1 part bleach. Deborah Cannon of the Special Pathogens Branch processing SARS specimens. Photo courtesy CDC / Anthony Sanchez. O PY Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS) W H Seto, D Tsang, R W H Yung, T Y Ching, T K Ng, M Ho, L M Ho, J S M Peiris Lancet Volume 361 Issue 9368 Page 1519. Sources 4. 5. 6. 7. 8. 9. Sources C Centers for Disease Control and Prevention (CDC). Severe Acute Respiratory Syndrome Supplement F: Laboratory Guidance, Appendices. January 8, 2004, http://www.cdc.gov/sars Centers for Disease Control and Prevention (CDC). In the Absence of SARS-CoV Transmission Worldwide: Guidance for Surveillance, Clinical and Laboratory Evaluation, and Reporting, Version 2. January 21, 2004. http://www.cdc.gov/sars Centers for Disease Control and Prevention (CDC). Current SARS Situation. May 3, 2005. http://www.cdc.gov/ncidod/sars/situation.htm Centers for Disease Control and Prevention (CDC). Frequently Asked Questions About SARS. April 26, 2004. http://www.cdc.gov/sars Scientist Live. Evolution of SARS. February 20, 2008. www.scientistlive.com/lab/?/Biotechnology/2008/02/20/19826/Evolution_of_SARS/ Wai Zeng. SARS Vaccine: A Bit Spiky. Nature China. January 30, 2008. www.nature.com/nchina/2008/080130/full/nchina.2008.20.html Cui, J., et al. Evoluationary Relationships Between Bat Coronaviruses and Their Hosts. Emerging Infectious Diseases, Vol. 13, No. 10, Ovtober 2007. http://www.cdc.gov/eid Krumkamp, R., et al., Impact of public health interventions in controlling the spread of SARS: Modelling of intervention scenarios. Int. J. Hyg. Environ. Health (2008), doi:10.1016/j.ijeh.2008.01.004. Radiological appearance of recent atypical pneumonias in Hong Kong. Prepared by Drs. Anil T. Ahuja & Jeffrey K. T. Wong. Maintained by Drs. James F. Griffith & Gregory E. Antonio. 2003. http://www.droid.cuhk.edu.hk/web/atypical_pneumonia/atypical_pneumonia.htm 12. 13. 14. 15. 16. 17. 18. 19. D O 10. T 3. 11. O 2. Shirley Chan, H. Jonathan Chong, Tevis Howard, Sarah Kimball, Michael Soule. SARS-CoV Epidemiology. Bio 160: Development of Vaccines to Infectious Diseases. Brown University, Providence, Rhode Island. April 2004. Mayo Clinic Staff. Infectious Disease: SARS. Mayo Foundation for Medical Education and Research. (MFMER) Oct. 6, 2006. http://www.mayoclinic.com/health/sars/DS00501/DSECTION=8 Mayo Clinic Staff. SARS. Mayo Foundation for Medical Education and Research. (MFMER) Oct. 6, 2006. http://www.mayoclinic.com/print/sars/DS00501/DSECTION=all&METHOD=print MedicineNet.com. SARS, Prevention and Protection. 7/7/2004. www.medicinenet.com/script/main/art.asp?articlekey=22882 The New York Times. Severe Acute Respiratory Syndrome SARS Overview. A.D.A.M., Inc., 1997-2008. http://health.nytimes.com/health/guides/disease/severe-acute-respiratory-syndromesars/overview.html?WT.z_gsac=1 Centers for Disease Control and Prevention (CDC). Fact Sheet for SARS Patients and Their Close Contacts. February 6, 2004. http://www.cdc.gov/sars Centers for Disease Control and Prevention (CDC). Clinical Guidance on the Identification and Evaluation of Possible SARS-CoV Disease among Persons Presenting with CommunityAcquired Illness. January 8, 2004. http://www.cdc.gov/sars Peiris J, et.al. Severe Acute Respiratory Syndrome, Current Concepts. NEJM (349)2431-41. 2003. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS) W H Seto, D Tsang, R W H Yung, T Y Ching, T K Ng, M Ho, L M Ho, J S M Peiris Lancet Volume 361 Issue 9368 Page 1519. Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2. Supplement D: Community Containment Measures, Including Non-Hospital Isolation and Quarantine, page 29. N 1. Pacific EMPRINTS The Pacific Emergency Management, Preparedness, and Response Information Network and Training Services is funded by the U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response Grant No. T01HP6427-0100. These materials may not be used or distributed in part or in entirety without written permission from Pacific EMPRINTS. 3 Infectious Diseases: SARS Pacific EMPRINTS Course Transcript Slide 1: “Infectious Diseases: SARS” Welcome to the “Infectious Diseases: SARS” tutorial designed by the Pacific Emergency Management, Preparedness, and Response Information Network and Training Services at the University of Hawaii at Manoa. C O PY Slide 2: “Severe Acute Respiratory Syndrome (SARS)” The Severe Acute Respiratory Syndrome, also known as SARS, is a viral respiratory illness caused by the SARS-associated coronavirus, or SARS-CoV. Coronaviruses cause infection in animals as well as humans. In humans, they tend to cause respiratory tract infections, such as the common cold. Coronaviruses have also been linked with gastroenteritis in humans as well. Researchers suspect that SARS-CoV may be a mutated form of a coronavirus found in an animal that has contact with humans. Although this animal reservoir is currently unknown, recent research indicates that the coronavirus that infects humans may have originated in bats. D O N O T Slide 3: “2003 SARS Outbreak” In February of 2003, SARS was first reported in food handlers in Southern China, heralding the highly-publicized 2003 SARS outbreak, which spread to more than two dozen countries, including North America, South America, Europe, and Asia. The outbreak was declared contained by July 2003. During this period, approximately 8,000 people worldwide became sick with SARS, including eight people with laboratory-confirmed SARS-CoV infection in the United States. Around 800 people died as a result of SARS, and the case-fatality rate for this outbreak was around ten percent. The last known human cases of SARS-CoV infection were reported in China in April 2004, due to laboratory-acquired infections. According to the Centers for Disease Control and Prevention, there is currently no known SARS transmission anywhere in the world. Slide 4: “SARS-CoV Transmission” Humans contract SARS via mucous membrane contact with infectious droplets or fomites. Droplet spread generally occurs when an infected person coughs or sneezes, propelling droplets approximately three feet. The virus can also spread when a person touches a surface contaminated by the SARS-CoV. SARS-CoV can survive on surfaces for up to two days at room temperature, and up to four days in stool. Maximal virus excretion occurs at about ten days in the respiratory tract, and at about thirteen days in stool. Pacific EMPRINTS is funded by the U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response Grant No. T01HP6427-0100. These materials may not be used or distributed in part or in entirety without written permission from Pacific EMPRINTS. Slide 5: “Risk Factors” Household or other close contact with an infected person leads to the highest risk of SARS-CoV infection. Close contact includes kissing or embracing, sharing utensils, close conversation, physical examination, and any other sort of direct physical contact between people. Close contact does not include sitting across from a person in an office or waiting room. However, close contact between people does occur in healthcare settings, where healthcare workers are likely to have contact with an infected person’s respiratory secretions and other bodily fluids. As a result twenty-one percent of global SARS cases have been found in healthcare workers. Although several cases of transmission that occurred during air travel were highly publicized during the 2003 SARS outbreak, air travel is only associated with a slightly increased risk of contracting SARS. O PY Slide 6: “Incubation” Patients usually become ill within two to ten days, with a mean incubation period of four to six days. However, other coronaviruses have the ability to remain in incubation for much longer, suggesting that some infected persons carry the virus for longer than the World Health Organization’s current projections. D O N O T C Slide 7: “SARS Criteria” The case definition for suspect and probable SARS provided by the Centers for Disease Control and Prevention includes both clinical and epidemiologic criteria. As far as clinical criteria goes, a moderate respiratory illness would be characterized by a temperature of over 100.4 degrees Fahrenheit or over 38 degrees Celsius, and one or more clinical findings of respiratory illness, such as cough, shortness of breath, difficulty breathing, or hypoxia. Clinical criteria for severe respiratory illness also includes a temperature over 100.4 degrees Fahrenheit and one or more clinical findings of respiratory illness. In addition, for a classification of severe respiratory distress, there will be radiographic evidence of pneumonia, or respiratory distress syndrome, or autopsy findings consistent with pneumonia or respiratory distress syndrome without an identifiable cause. Epidemiologic criteria for suspect and probable SARS includes travel, including transit in an airport, within 10 days of onset of symptoms to an area with current or recently documented or suspected community transmission of SARS, or close contact within 10 days of onset of symptoms with a person known or suspected to have SARS infection. Slide 8: “Diagnosis” Researchers are working on the development of laboratory tests to improve diagnostic capabilities for SARS-CoV. However, no specific clinical or laboratory findings have yet been identified that can definitively and rapidly differentiate SARS-CoV from other respiratory illnesses during the early stages of infection. Therefore, early clinical recognition of SARS still relies on a combination of clinical and epidemiologic features, as elucidated in the previous slide by the CDC. The majority of patients with SARS have both a clear history of exposure either to a SARS patient, or to a setting in which SARS-CoV transmission is Pacific EMPRINTS is funded by the U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response Grant No. T01HP6427-0100. These materials may not be used or distributed in part or in entirety without written permission from Pacific EMPRINTS. occurring, and also develop pneumonia. Diagnosis of SARS should be based on risk of exposure, such as recent travel to a SARS-affected area, or close contact with an ill person with a suspicious travel history. PY Slide 9: “Laboratory Criteria” Laboratory work can confirm SARS if there is a detection of antibody to SARSCoV in specimens obtained during acute illness or over 21 days after the onset of illness. It can also be confirmed via detection of SARS-CoV RNA by RT-PCR confirmed by a second PCR assay, by using a second aliquot of the specimen and a different set of PCR primers. Finally, SARS may be confirmed by the isolation of SARS-CoV by a lab or by electron microscopy of SARS-CoV. A negative for SARS may be obtained if an absence of antibody to SARS-CoV in convalescent serum is found over 21 days after symptom onset. SARS is considered undetermined if laboratory testing is either not performed or incomplete. D O N O T C O Slide 10: “Additional Findings” According to the New England Journal of Medicine, other laboratory findings that may be associated with SARS include increases in serum alanine aminotransferase, lactate dehydrogenase, creatine kinase and prothrombin time. Lymphocyte and platelet counts are often decreased. However, each of these changes occurs in less than 50% of cases and none is specific for SARS. Radiological findings in Hong Kong patients with SARS were as follows, according to Doctors Anil T. Abuia and Jeffrey K.T. Wong. “In the early stage of the disease, a peripheral / pleural-based opacity may be the only abnormality. This may range from ground-glass to consolidation in appearance. A particular area to review is the paraspinal region behind the heart. In our experience, this is frequently where lung lesions are detected on High Resolution Computed Tomography in suspected SARS patients with normal radiographs. In the more advanced cases, there is widespread opacification which may be ground-glass or consolidative affecting large areas. This tends to affect the lower zones first and is not uncommonly bilateral. Calcification, cavitation, pleural effusion or lymphadenopathy are not features of this disease.” Slide 11: “Treatment” Suspected or probable SARS cases should be hospitalized and isolated. The CDC recommends that patients with SARS receive the same treatment that would be used for a patient with any serious community-acquired atypical pneumonia. Lopinavir-ritonavir, in conjunction with ribavirin has been shown in clinical studies to prevent serious complications and death from SARS. However, currently, there is no effective treatment for SARS, and further testing is needed in this area. Supportive care in the form of supplemental oxygen, chest physiotherapy, or mechanical ventilation is sometimes needed for SARS cases. Pacific EMPRINTS is funded by the U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response Grant No. T01HP6427-0100. These materials may not be used or distributed in part or in entirety without written permission from Pacific EMPRINTS. Slide 12: “Isolation” Isolation of symptomatic patients is an important measure in SARS, as it is likely that patients have to be symptomatic to be infectious. The spread of SARS is best prevented by isolating patients from the time of the onset of their symptoms. Expeditious isolation, however, is difficult to achieve. Early in the 2003 epidemic, in Singapore, the average time that patients were symptomatic before being placed in isolation was 7 days. A prominent feature of the 2003 SARS epidemic was the spread in hospital settings. The simultaneous appearance of severe respiratory infection in healthcare workers is an early tip-off to an epidemic of SARS. N O T C O PY Slide 13: “Personal Prevention” The following precautions should be employed by those caring for someone with SARS, for at least ten days after respiratory symptoms and fever are gone. Hands should be washed frequently with soap and hot water, or an alcoholbased hand rub containing at least 60 percent alcohol. Avoid touching the face and mouth. If necessary, tissue may be used to wipe the eyes and nose. Disposable gloves should be worn during contact with an infected person’s bodily fluids, respiratory secretions, or feces. Immediately after contact, the gloves should be removed and discarded. A surgical mask should be worn when in the same room as the infected person. Glasses or goggles may also offer some protection against SARS-CoV transmission. Utensils, towels, bedding, and clothing used by the infected person should also be washed with soap and hot water. A household disinfectant can be used to clean any surfaces that may have come into contact with the infected person. In addition, the SARS virus is easily killed by a chlorine solution of 99 parts water to 1 part bleach. D O Slide 14: “Future Prevention” There is still much work to be done if outbreaks of SARS are to be prevented in the future. A vaccine capable of combating SARS-CoV is still needed. Research in this area includes a possible recombinant vaccine for SARS-CoV that has been developed by scientists in China, and is currently undergoing testing. Although SARS can be confirmed by laboratory testing, laboratory tests that detect SARS-CoV during the early stages of infection would be helpful in identifying SARS cases and preventing outbreaks. Also helpful in this regard is identifying potential animal reservoirs for SARS-CoV, of which several have been found. As in the 2003 outbreak, international cooperation and collaboration in monitoring and identifying potential SARS cases remains essential in mitigating a potential outbreak. Slide 15: “Sources” The displayed sources were consulted in the development of this tutorial. Slide 16: “Sources” Development of this tutorial was assisted, in part, by subject matter expert Alan Katz, MD, MPH. Pacific EMPRINTS is funded by the U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response Grant No. T01HP6427-0100. These materials may not be used or distributed in part or in entirety without written permission from Pacific EMPRINTS. Slide 17: “Pacific EMPRINTS” The Pacific Emergency Management, Preparedness, and Response Information Network and Training Services is funded by the U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response Grant Number T01HP6427-0100. D O N O T C O PY Sources: 1. Shirley Chan, H. Jonathan Chong, Tevis Howard, Sarah Kimball, Michael Soule. SARS-CoV Epidemiology. Bio 160: Development of Vaccines to Infectious Diseases. Brown University, Providence, Rhode Island. April 2004. 2. Mayo Clinic Staff. Infectious Disease: SARS. Mayo Foundation for Medical Education and Research. (MFMER) Oct. 6, 2006. http://www.mayoclinic.com/health/sars/DS00501/DSECTION=8 3. Mayo Clinic Staff. SARS. Mayo Foundation for Medical Education and Research. (MFMER) Oct. 6, 2006. http://www.mayoclinic.com/print/sars/DS00501/DSECTION=all&METHOD =print 4. MedicineNet.com. SARS, Prevention and Protection. 7/7/2004. www.medicinenet.com/script/main/art.asp?articlekey=22882 5. The New York Times. Severe Acute Respiratory Syndrome SARS Overview. A.D.A.M., Inc., 1997-2008. http://health.nytimes.com/health/guides/disease/severe-acute-respiratorysyndrome-sars/overview.html?WT.z_gsac=1 6. Centers for Disease Control and Prevention (CDC). Fact Sheet for SARS Patients and Their Close Contacts. February 6, 2004. http://www.cdc.gov/sars 7. Centers for Disease Control and Prevention (CDC). Clinical Guidance on the Identification and Evaluation of Possible SARS-CoV Disease among Persons Presenting with Community-Acquired Illness. January 8, 2004. http://www.cdc.gov/sars 8. Peiris J, et.al. Severe Acute Respiratory Syndrome, Current Concepts. NEJM (349)2431-41. 2003. 9. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS) W H Seto, D Tsang, R W H Yung, T Y Ching, T K Ng, M Ho, L M Ho, J S M Peiris Lancet Volume 361 Issue 9368 Page 1519. 10. Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2. Supplement D: Community Containment Measures, Including NonHospital Isolation and Quarantine, page 29. 11. Centers for Disease Control and Prevention (CDC). Severe Acute Respiratory Syndrome Supplement F: Laboratory Guidance, Appendices. January 8, 2004, http://www.cdc.gov/sars 12. Centers for Disease Control and Prevention (CDC). In the Absence of SARS-CoV Transmission Worldwide: Guidance for Surveillance, Clinical Pacific EMPRINTS is funded by the U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response Grant No. T01HP6427-0100. These materials may not be used or distributed in part or in entirety without written permission from Pacific EMPRINTS. D O N O T C O PY and Laboratory Evaluation, and Reporting, Version 2. January 21, 2004. http://www.cdc.gov/sars 13. Centers for Disease Control and Prevention (CDC). Current SARS Situation. May 3, 2005. http://www.cdc.gov/ncidod/sars/situation.htm 14. Centers for Disease Control and Prevention (CDC). Frequently Asked Questions About SARS. April 26, 2004. http://www.cdc.gov/sars 15. Scientist Live. Evolution of SARS. February 20, 2008. www.scientistlive.com/lab/?/Biotechnology/2008/02/20/19826/Evolution_of _SARS/ 16. Wai Zeng. SARS Vaccine: A Bit Spiky. Nature China. January 30, 2008. www.nature.com/nchina/2008/080130/full/nchina.2008.20.html 17. Cui, J., et al. Evoluationary Relationships Between Bat Coronaviruses and Their Hosts. Emerging Infectious Diseases, Vol. 13, No. 10, Ovtober 2007. http://www.cdc.gov/eid 18. Krumkamp, R., et al., Impact of public health interventions in controlling the spread of SARS: Modelling of intervention scenarios. Int. J. Hyg. Environ. Health (2008), doi:10.1016/j.ijeh.2008.01.004. 19. Radiological appearance of recent atypical pneumonias in Hong Kong. Prepared by Drs. Anil T. Ahuja & Jeffrey K. T. Wong. Maintained by Drs. James F. Griffith & Gregory E. Antonio. 2003. http://www.droid.cuhk.edu.hk/web/atypical_pneumonia/atypical_pneumoni a.htm Pacific EMPRINTS is funded by the U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response Grant No. T01HP6427-0100. These materials may not be used or distributed in part or in entirety without written permission from Pacific EMPRINTS.