SEVERE ACUTE RESPIRATORY SYNDROME (SARS)

Severe Acute Respiratory

Syndrome (SARS)

A. Introduction
It is newly recognized form of a typical pneumonia that had been
described in patients in Asia, North America and Europe. The earliest known
cases were identified from Guangdong Province, China in November, 2002. The
WHO issued the global alert on the outbreak on March 12, 2003 and instituted
worldwide surveillance. The first case in the Philippines was recognized on April
11, 2003 in a Caucasian business commuter between Hong Kong and Manila.

B. Statistics

It had been an epidemic disease between the months of November 2002

and July 2003. From the April 21, 2004 report of the WHO there are 774 deaths,
and 8,096 known infected areas of SARS worldwide. In just a matter of weeks in
early 2003, SARS had spread continuously in the province of Guangdong in
China. The disease rapidly infects many individuals from 37 countries
worldwide.

As of May 8, 2003, the mortality rates of age groups for the SARS disease
is below 1% for people aged 24 and younger, 6% for those age 25 to 44, and
15% for those age 45 to 64, and more than 50% for those above 65 years old.
For the record, the case fatality for influenza is usually around 6% primarily for
the elderly but can rise up to 33% in the local severe epidemic areas.
Meanwhile, the mortality rate of the primary viral pneumonia is about 70%.

As of May 2006, the spread of SARS had been fully controlled by the
World Health Organization. The last infected human case was seen in June
2003. However, the disease of SARS is not claimed to have been fully
eradicated just like small pox. There is a great possibility that the disease is still
present in its natural host reservoirs most likely in animal populations. It can
even potentially return in the future among human population in a much
different form.

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C. Infectious Agent

Severe Acute Respiratory Syndrome (SARS) is caused by a coronavirus,

called SARS-associated coronavirus (SARS-CoV).

Coronaviruses are positive-strand and enveloped RNA viruses that are

important pathogens of birds and mammals. This is a group of viruses that
cause respiratory tract infections in various animals that include pets, livestock,
and even humans.

The SARS coronavirus is the causative agent of the syndrome. In Hong

Kong and Germany, an initial electron microscopic examination was conducted.
In this examination, some viral particles with structures were found to have
paramyxovirus. This vrus was respiratory secretions from patients who are
SARS infected.

D.Mode of Transmission
Close contact with respiratory droplet secretion from SARS patient.
Transmission occurs when another person’s mucous membranes (mouth, nose
and eyes) are exposed to droplet secretions in the air but may travel for a short
distance three feet then settle on surfaces.

E. Period of Communicability
SARS-CoV is not thought to be transmissible during the asymptomatic
incubation period and there has been no evidence that the virus has been
spread ten days after fever has resolved.

F. Signs and Symptoms, and Pathognomonic Feature

The only symptom that is common to all patients appears to be a fever

above 38 °C (100.4 °F). This include the occurrence of initial symptoms are flu-

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like and may include: myalgia, lethargy, gastrointestinal symptoms, cough, sore
throat and other non-specific symptoms like shortness of breath.

Prodromal Phase:

Fever > 38oC sometime with chill, malaise, myalgia and headache. Rash and
neurologic or gastrointestinal findings are typically absent, although some
patients have reported diarrhea during febrile prodrome. During this stage, the
infectivity is none to low.

Respiratory Phase:

Within 2-7 days, the illness may proceed to this stage characterized by dry.
nonproductive cough with or without respiratory distress. Common findings
include hypoxia and crackles or rales, dullness on percussion and decreased
breath sounds on physical examination. In 10%-20% of cases, the respiratory
illness is severe enough o progress to acute respiratory distress syndrome
requiring mechanical ventilation. Infectivity is highest during the respiratory
phase.

G.Pathophysiology

Intranasal inoculation induces colds in a small percentage of volunteers,

although virus replication in nasal epithelium is detected in most volunteers.
Colds are generally mild, self-limited infections, and significant increases in
neutralizing antibody titer are found in nasal secretions and serum after
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infection. Nevertheless, some unlucky individuals can be reinfected with the

same coronavirus soon after recovery and get symptoms again. Coronavirus
colds are more frequent in winter, and the two known human coronaviruses
vary in prevalence from year to year. If SARS becomes established in humans,
will it also have a seasonal incidence of clinical disease? Prospective studies of
hospitalized patients showed that human respiratory coronaviruses only rarely
cause lower respiratory tract infection, perhaps in part because they grow
poorly at 37°C. Although coronavirus-like particles have been observed by
electron microscopy in human feces, and serological studies of necrotizing
enterocolitis in infants occasionally show rises in antibody titer to coronaviruses,
infectious human coronaviruses have been, until SARS, extremely difficult to
isolate from feces.

Coronaviruses cause economically important diseases of livestock,

poultry, and laboratory rodents. Most coronaviruses of animals infect epithelial
cells in the respiratory and/or enteric tracts, causing epizootics of respiratory
diseases and/or gastroenteritis with short incubation periods (2–7 days), such as
those found in SARS. In general, each coronavirus causes disease in only one
animal species. In immunocompetent hosts, infection elicits neutralizing
antibodies and cell-mediated immune responses that kill infected cells. In SARS
patients, neutralizing antibodies are detected 2–3 weeks after the onset of
disease, and 90% of patients recover without hospitalization. In animals,
reinfection with coronaviruses is common, with or without disease symptoms.
The duration of shedding of SARS-CoV from respiratory secretions of SARS
patients appears to be quite variable. Some animals can shed infectious
coronavirus persistently from the enteric tract for weeks or months without
signs of disease, transmitting infectious virus to neonates and other susceptible
animals. SARS-CoV has been detected in the feces of patients by RT-PCR and
virus isolation. Studies are being done to learn whether SARS-CoV is shed
persistently from the respiratory and/or enteric tracts of some humans without
signs of disease. Host factors such as age, strain or genotype, immune status,
coinfection with other viruses, bacteria, or parasites, and stress affect
susceptibility to coronavirus-induced diseases of animals, and the ability to
spread virus to susceptible animals. It is important to learn what host factors
and/or virus differences are responsible for the “super-spreader” phenomenon
observed in SARS, in which a few patients infect many people through brief
casual contact or possibly environmental contamination, even though most
patients infect only people in close contact with them during the period of overt
disease.

H. Susceptibility & Resistance

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The elderly are more prone to severe disease and pose a particular
challenge in the recognition of SARS as they may present with an afebrile illness
or with a concurrent bacterial sepsis or pneumonia.

In the setting of a SARS outbreak the diagnosis should be considered for

almost any change in health status, even in the absence of typical clinical
features of SARS-CoV disease, when such patients have epidemiologic risk
factors for SARS-CoV disease (e.g. close contact with someone suspected to
have SARS-CoV disease or exposure to a location [domestic or international]
with documented or suspected recent transmission of SARS-CoV).

During the 2003 outbreaks, infants and children accounted for only a
small percentage of patients and had much milder disease with better
outcomes. There have been two reported cases of transmission from children to
adults and no reports of transmission from children to other children. Three
separate epidemiological investigations have found no evidence of SARS
transmission in schools. Furthermore, no evidence of SARS has been found in
infants of mothers who were infected during pregnancy. Further investigation is
required to determine whether children may have asymptomatic or mild
infections.

I. Diagnostic Test

SARS may be suspected in a patient who has:

1. Any of the symptoms, including a fever of 38 °C (100.4 °F) or higher, and

2. Either a history of:
1. Contact (sexual or casual) with someone with a diagnosis of SARS
within the last 10 days OR
2. Travel to any of the regions identified by the WHO as areas with
recent local transmission of SARS (affected regions as of 10 May
2003[5] were parts of China, Hong Kong, Singapore and the province
of Ontario, Canada).

A probable case of SARS has the above findings plus positive chest X-ray
findings of atypical pneumonia or respiratory distress syndrome.

With the advent of diagnostic tests for the coronavirus probably

responsible for SARS, the WHO has added the category of "laboratory confirmed
SARS" for patients who would otherwise fit the above "probable" category who
do not (yet) have the chest x-ray changes but do have positive laboratory
diagnosis of SARS based on one of the approved tests (ELISA,
immunofluorescence or PCR).
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The chest X-ray (CXR) appearance of SARS is variable. There is no

pathognomonic appearance of SARS but is commonly felt to be abnormal with
patchy infiltrates in any part of the lungs. The initial CXR may be clear.

White blood cell and platelet counts are often high. Early reports indicated
a tendency to relative neutrophilia and a relative lymphopenia — relative
because the total number of white blood cells tends to be low. Other laboratory
tests suggest raised lactate dehydrogenase and slightly raised creatine kinase
and C-Reactive protein levels.

Three possible diagnostic tests have emerged, each with drawbacks. The
first, an ELISA (enzyme-linked immunosorbent assay) test detects antibodies to
SARS reliably but only 21 days after the onset of symptoms. The second, an
immunofluorescence assay, can detect antibodies 10 days after the onset of the
disease but is a labour and time intensive test, requiring an
immunofluorescence microscope and an experienced operator. The last test is a
polymerase chain reaction (PCR) test that can detect genetic material of the
SARS virus in specimens ranging from blood, sputum, tissue samples and stools.
The PCR tests so far have proven to be very specific but not very sensitive. This
means that while a positive PCR test result is strongly indicative that the patient
is infected with SARS, a negative test result does not mean that the patient
does not have SARS.

J. Prevention
Persons in direct, close contact with someone who has had SARS are at
greatest risk for infection. Persons with SARS or those at risk for SARS should
follow the guidelines outlined below. The WHO and CDC have established
guidelines to help in the prevention and spread of SARS.

 Limit time outside of the home. Persons with SARS should not go
to work, school, childcare facilities, or any public place until 10 days
after their fever has ended and their respiratory symptoms are
improving.

 Wash hands frequently with soap and hot water, use an alcohol-
based hand rub, or both, especially after being in contact with bodily
fluids such as respiratory fluids or urine.

 Wear disposable gloves when in contact with bodily fluids from a

person with SARS. After use, throw the gloves away immediately and
thoroughly wash the hands.

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 Wear a surgical mask.

 Cover the nose and mouth with a tissue when sneezing or

coughing.

 Do not share eating utensils, towels, or bedding. Thoroughly

wash these items with soap and hot water after use by a person who
is infected.

 Use a household disinfectant on any surface that may be

contaminated, such as countertops or doorknobs. Wear disposable
gloves while cleaning these surfaces.

K. Medical Treatment
Currently, no specific treatment exists for SARS, although various
treatments have been tried with unclear success.

Persons with confirmed or suspected SARS should be isolated and

undergo aggressive treatment in a hospital. Mechanical ventilation (a device
that assists in a person's breathing) and critical care may be necessary.

Persons suspected of having SARS should be evaluated immediately by a

health care provider, and hospitalized under isolation if they meet the definition
of a suspected or probable case.

Treatment may include:

• Antibiotics to treat bacterial causes of atypical pneumonia

• Antiviral medications
• High doses of steroids to reduce lung inflammation
• Oxygen, breathing support (mechanical ventilation), or chest
physiotherapy

In some serious cases, blood serum from people who have already
recovered from SARS has been given. There is no strong evidence that these
treatments work well.

L. Nursing Responsibilities

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Health care facilities should ensure the availability of materials for

adhering to respiratory hygiene/cough etiquette in waiting areas for patients
and visitors:

 provide tissues and no-touch receptacles for used tissue disposal

 provide conveniently located dispensers for alcohol-based hand
rub
 provide soap and disposable towels/hand driers for hand washing
where sinks are available.

During periods of increased respiratory infection in the community, it may

be possible for healthcare facilities to offer surgical masks to persons who are
coughing and encourage coughing persons to sit at least three feet away from
others in waiting areas.

Healthcare workers should practice droplet precautions, in addition to

standard precautions, when examining a patient with symptoms of a respiratory
infection.

Once there exists an index of suspicion of SARS then the appropriate

infection control measures need to be activated and suitable PPE worn, (see
www.icg.health.gov.au). These will dependent on the specific facility involved
and the resources available at the time. They include:

 use of standard precautions (ie hand hygiene) and contact and

droplet precautions (ie use of long-sleeved gowns, gloves and
protective eyewear for contact with patient or environment)
 use of airborne precautions that include the use of a P2 (N95
equivalent) mask (respirator) for all persons entering the room and
where available, a negative pressure respiratory isolation room (with
en-suite)
 restriction of patient movement (and fitting of a surgical mask if
they must leave their room)
 avoiding the use of nebulisers, chest physiotherapy,
bronchoscopy, gastroscopy or any intervention that may disrupt the
respiratory tract
 placing surgical masks over nasal oxygen prongs.

It will become increasingly important for clinicians to elicit epidemiological

information from their patients as part of normal history taking. Travel history,
recent attendance to hospitals or exposure to others who are ill, may assist in
the refinement of a patient’s differential diagnosis and associated risk.

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Source:
Public Health Nursing in the Philippines by the Publications Committee, National League of
Philippine Government Nurses, Incorporated
http://www.mass.gov/Eeohhs2/docs/dph/disease_reporting/guide/sars.pdf
http://www.health.vic.gov.au/ideas/bluebook/sars

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