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The
outbreak of ‘Severe acute respiratory syndrome’
(SARS) illness had spread around the world in
a very short time showing clear evidence that
this agent has potential for global spread.
SARS, that was first recognised on 26 February
2003 in Hanoi, Vietnam, had spread to 32 countries
of the world, causing nearly 8439 cases and
812 deaths worldwide from November 1, 2002 to
July 4, 2003. The SARS virus is a new ‘coronavirus’
unlike any other known human or animal virus
in the Coronavirus family.
The most affected countries
are China (Guandong province), Hong Kong Special
Administrative region, Macao Special Administrative
region, Taiwan, Vietnam, Philippines, Singapore
and Thailand in Asia and Toronto (Canada) in
North America. No case was reported in Bangladesh
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Highlights
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SARS, that was first
recognised on 26 February 2003 in Hanoi,
Vietnam, had spread to 32 countries of
the world, causing nearly 8439 cases and
812 deaths worldwide from November 1,
2002 to July 4, 2003
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1) WHO’s Case definition:
a) Suspect case
- A person presenting after 1 November 2002(1)
with history of: high fever (>38 °C)
and cough or breathing difficulty and one
or more of the following exposures during
the 10 days prior to onset of symptoms.
- Close contact(2) with a person who is
a suspect or probable case of SARS;
history of travel to an affected area(3)
residing in an affected area(3)
- A person with an unexplained acute respiratory
illness resulting in death after 1 November
2002, (1) but on whom no autopsy has been
performed
and one or more of the following exposures
during 10 days prior to onset of symptoms
- Close contact, (2) with a person who is
a suspect of probable case of SARS;
history of travel to an affected area (3)
residing in an affected area (3)
- A person with an unexplained acute respiratory
illness resulting in death after 1 November
2002, (1) but on whom no autopsy has been
performed and one or more of the following
exposures during 1 days prior to onset of
symptoms.
b) Probable case
- A suspect case with radiographic evidence
of infiltrates consistent with pneumonia
or respiratory distress syndrome (RDS) on
chest X-ray (CXR).
- A suspect case with autopsy findings consistent
with the pathology of RDS without an identifiable
cause.
- Exclusion criteria: A case should be excluded
if an alternative diagnosis can fully explain
their illness.
- The surveillance period begins on 1 November
2002 to capture cases of atypical pneumonia
in China now recognised as SARS. International
transmission of SARS was first reported
in March 2003 for cases with onset in February
2003.
- Close contact: having cared for, lived
with, or had direct contact with respiratory
secretions or body fluids of a suspect or
probable case of SARS.
- Affected area: an area in which local
chain(s) of transmission of SARS is/are
occurring as reported by the national public
health authorities.
c) Pending availability
of a globally accepted case definition, clustering
of atypical pneumonia cases, especially in health
care workers should be investigated as a possible
outbreak of SARS. The surveillance mechanism
should be operationalised on an efficient multi-tier
referral system.
2) Identification of Causative
agent:
A field-compatible, validated,
rapid, sensitive and specific laboratory diagnostic
tests should be made available. Till such kit
is developed, PCR test facilities for SARS is
at present available. At least one laboratory
at national level must have bio-safety level
(BSL) 3 facilities and expertise to handle highly
infectious material including that of SARS,
failing which linkages with other laboratory
be established as per WHO guidelines for referral
laboratories.
3) Management:
a. Management of Suspect
and Probable SARS Cases
- Hospitalise under isolation or cohort with
other suspect or probable SARS cases. Take
samples (sputum, blood, sera, urine) to exclude
standard causes of pneumonia (including atypical
causes); consider possibility of co-infection
with SARS and take appropriate chest radiographs.
- Take samples to aid clinical diagnosis of
SARS including: White blood cell count, platelet
count, creatine phosphokinase, liver function
tests, urea and electrolytes, C reactive protein
and paired sera. (Pair sera will be invaluable
in the understanding of SARS even if the patient
is later not considered a SARS case).
- At the time of admission the use of antibiotics
for the treatment of community-acquired pneumonia
with atypical cover is recommended.
- Pay particular attention to therapies/interventions,
which may cause aerolisation such as the use
of nebulisers with a bronchodilator, chest
physiotherapy, bronchoscope, gastroscopy,
and any procedure/intervention, which may
disrupt the respiratory tract. Take the appropriate
precautions (isolation facility, gloves, goggles,
mask, gown, etc.) if you feel that patients
require the intervention/therapy.
- In SARS, numerous antibiotic therapies have
been tried with no clear effect. Ribavirin
with or without use of steroids has been used
in an increasing number of patients. But,
in the absence of clinical indicators, its
effectiveness has not been proven.
Definition of a SARS Contact
A contact is a person who may be at greater
risk of developing SARS because of exposure
to a suspect or probable case of SARS. Information
to date suggests that risky exposures include
having cared for, lived with, or having had
direct contact with the respiratory secretions,
body fluids and/or excretion (e.g. faeces) of
a suspect or probable cases of SARS.
b. Management of Contacts
of Probable SARS Cases
- Give information on clinical picture, transmission,
etc. of SARS to the contact
- Place under active surveillance for 10 days
and recommend voluntary home isolation
- Ensure contact is visited or telephoned
daily by a member of the public health care
team
- Record temperature daily
- If the contact develops disease symptoms,
the contact should be investigated locally
at an appropriate health care facility
- The most consistent first symptom that is
likely to appear is fever
c. Management of Contacts
of Suspect SARS Cases
As a minimum, the following follow-up is recommended:
- Give information on clinical picture, transmission
etc of SARS to the contact
- Place under passive surveillance for 10
days
- If the contact develops any symptoms, the
contact should self report via the telephone
to the public health authority
- Contact is free to continue with usual activities
- The most consistent first symptom which
is likely to appear is fever
Most national health authorities may wish to
consider risk assessment on an individual basis
and supplement the guidelines for the management
of contacts of suspected SARS cases accordingly
d. Management of contacts
of suspected and probable cases:
- Provide reassurance
- Record name and contact details
- Provide advice on immediate reporting to
health authorities, take leave from the work
until advised.
- Avoid public places and minimise contact
with family members and friends
- Antibiotics have no role in clinical improvement
- Good supportive care including intensive
therapy improves prognosis
- Antiviral agent Ribavirin in combination
with high dose of corticosteroides
4) WHO Travel Advice
Summary of WHO measures related
to international travel in 2003
WHO no longer recommends the restriction of
travel to any area as mentioned in the WHO update
96, which was released on July 05, 2003.
- As the outbreak of SARS has come under control,
the most important message for international
travelers is to continue to be aware of the
main symptoms of SARS:
high fever (> 38° Celsius, >100.4°
Fahrenheit), dry cough, shortness of breath
or breathing difficulties. Persons who experience
these symptoms and who, in the last 10 days
have been in an area, which has experienced
a recent outbreak of SARS, are advised to contact
a doctor.
WHO recommended measures to limit the international
spread of SARS
- In the absence of effective drugs or a vaccine
for SARS, control of this disease relies on
the rapid identification of cases and their
appropriate management, including the isolation
of suspect and probable cases and the management
of their close contacts. These measures have
allowed the outbreak of SARS to be controlled
and prevented imported cases from spreading
the disease to others.
- During the outbreak, to reduce the risk
that travellers would carry the SARS virus
to new areas, WHO made recommendations regarding
the screening of passengers leaving certain
areas and also the postponement of all but
essential travel to certain more severely
affected areas. All recommendations to postpone
travel have now been lifted. Recommendations
for the screening of departing passengers
have now ceased to apply as there are no longer
any areas with recent local transmission of
SARS.
- Travellers should be aware that as an additional
measure of precaution and to build public
confidence, some areas have decided to continue
to implement certain travel related measures
such as the screening of travellers for fever
or providing travellers with health information.
- Travellers are advised to contact their
doctors or national health authorities for
supplementary information as individual countries
may adopt WHO recommendations to take into
account national considerations. Many national
health authorities have established web sites
with excellent information.
For more information regarding
SARS, you may wish to consult the WHO website
at the following address:
http://www.whosea.org/sars
http://www.who.int/csr/sars
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