Download Pacific EMPRINTS - Infectious Diseases: SARS

Severe Acute Respiratory
Syndrome (SARS)
ƒ Viral respiratory illness caused by the
SARS-associated coronavirus (SARSCoV).
ƒ 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)
ƒ SARS-CoV may be a mutated form of a
coronavirus found in an animal that has
contact with humans.
ƒ 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
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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
ƒ Approximately 8,000 people
worldwide became sick with
SARS (eight people in the U.S.
had laboratory-confirmed
SARS-CoV infection).
ƒ Approximately 800 SARS
deaths; case-fatality rate
approximately 10%.
T
North America
South America
Europe
Asia
N
–
–
–
–
ƒ Via mucous membrane contact with infectious
droplets or fomites.
ƒ Spread by coughing and sneezing.
ƒ Travels approximately 3 feet in expelled droplets.
ƒ Survives up to 2 days at room temperature, and
up to 4 days in stool.
ƒ Maximal virus excretion occurs at about 10 days
in the respiratory tract, and at about thirteen days
in stool.
C
ƒ February 2003 – First reported
in food handlers in Southern
China.
ƒ Spread to more than two dozen
countries, including:
Risk Factors
ƒ Household or other close contact with an
infected person.
ƒ Healthcare settings:
– Twenty-one percent of global SARS cases have
been found in healthcare workers.1
ƒ Air travel is only associated with a slightly
increased risk.
1
Incubation
ƒ Patients usually become ill within 2-10
days; mean incubation period of 4-6 days.
ƒ 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
ƒ Clinical Criteria:
ƒ Early clinical recognition of SARS still relies
on a combination of clinical and
epidemiologic features.1
ƒ 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.
ƒ 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.
ƒ Diagnosis of SARS should be based on risk of
exposure.
for Disease Control and Prevention (CDC)
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1Centers
Additional Findings
Laboratory Criteria
ƒ 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
ƒ Negative:
– Absence of antibody to SARS-CoV
in convalescent serum obtained
>21 days after symptom onset
N
ƒ 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
ƒ
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.
ƒ
Treatment
ƒ Hospitalize and isolate suspected or probable cases of
SARS .
ƒ CDC recommends that patients with SARS receive the
same treatment that would be used for a patient with
any serious community-acquired atypical pneumonia.
ƒ Lopinavir-ritonavir, in conjunction with ribavirin has
been shown in clinical studies to prevent serious
complications and death.
ƒ Supportive care, such as supplemental oxygen, chest
physiotherapy or mechanical ventilation is sometimes
needed.
ƒ Further testing is needed to determine an effective
treatment for SARS.
Isolation
ƒ Isolation of symptomatic patients is an important
measure in SARS, as it is likely that patients have to
be symptomatic to be infectious.
ƒ 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.
ƒ 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
ƒ Find a vaccine to combat
SARS-CoV.
ƒ Develop laboratory tests
for early detection.
ƒ Identify potential animal
reservoirs for SARS.
ƒ International cooperation
in monitoring potential
SARS cases.
ƒ 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.
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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.
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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.
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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.
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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.
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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.
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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
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T
C
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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.
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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.
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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
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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.
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