Running head: SEVERE ACUTE RESPIRATORY SYNDROME
Severe Acute Respiratory Syndrome
Jessica A. Stewart
Ferris State University
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SEVERE ACUTE RESPIRATORY SYNDROME
Abstract
Severe acute respiratory syndrome is a serious form of viral pneumonia that is thought to have
spread from infected animals to humans (CDC, 2005). In 2003 the World Health Organization
(WHO) issued a pandemic for SARS which lasted for just over a year (Silverman, Simor, and
Louty, 2004). There has not been any further diagnosis of SARS since 2004—but the possibility
of another outbreak does exist (CDC, 2005). This paper includes clinical presentation, diagnosis,
transmission, and therapy for SARS. Additionally, this paper includes personal protective
equipment (PPE) that should be utilized in the event of a SARS outbreak as well as importance
of isolation. Analyses of evidence and factors and situations that may promote SARS are also
discussed.
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Severe Acute Respiratory Syndrome
Severe acute respiratory syndrome (SARS) is a form of viral pneumonia that was first
recognized in 2002 in China (Tseng, Sbrana, Iwata-Yoshikawa, Newman, Garron, Atmar, Peters,
& Couch, 2012). SARS is caused by a coronavirus and is thought to have spread from small
animals such as bats, cats, and raccoon dogs to humans in China ( Pyrc, Berkhout, & Van Der
Hoek, 2007) In 2003 Dr. Carlo Urbani, and physician of the World Health (WHO) defined
SARS as a new disease by diagnosing a 48-year-old traveling businessman from China—both
Dr. Urbani and the patient died from this virus (A.D.A.M. Medical Encyclopedia, 2011). SARS
quickly became a pandemic in 2003 and “took 774 lives around the glove and infected more than
8000 people in 29 countries” (Pyrc, et al., 2007, para 1). Although SARS is no longer circulating
in humans it is vital for health professionals to be well informed of clinical presentation,
diagnosis, transmission, and therapy in order to prevent future outbreaks of SARS.
Clinical Presentation
Presenting symptoms of SARS are common to those of a common cold. These
symptoms include a fever over 38.0 degrees Celsius, cough, difficulty breathing, chills,
headache, and muscle aches (A.D.A.M. Medical Encyclopedia, 2011). Common early symptoms
of SARS include chills, rigors, myalgia, and headache which may precede a fever by 12-24 hours
(CDC, 2004). Other symptoms that may present in SARS are rhinorrhea, diarrhea, and a sore
throat (CDC, 2004). Additionally, many people with SARS in 2003 experienced large joint
arthralgia, osteonecrosis, and reduced bone mass (Griffith, 2011).
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Diagnosis
According to the Centers for Disease Control and Prevention since 2004 there have been
not diagnosed cases of SARS (2005). Because SARS has not been detected since the pandemic
little research has been conducted in order to diagnose SARS. Researchers created reverse
transcription-polymerase chain reaction (RT-PCR) during the pandemic in order to find methods
of diagnosing SARS in future cases (Che, Hao, Wang, Di, Yin, Xu, Feng, Wan, Cheng, & Yuen,
2004). “Serum samples from 317 patients with SARS were tested for the nucleocapsid (N)
protein of SARS-associated coronavirus, with sensitivities of 94% and 78% for the first 5 days
and 6-10 days after onset, respectively. The specificity was 99.9% N protein can be used as an
early diagnosis marker for SARS” (Che, et al., 2004, para. 1).
Other methods of diagnosing SARS include ruling out other diagnoses by completing
several tests as well as by following algorithms. Compete blood count (CBC), blood clotting
tests, blood chemistry tests, and chest x-ray or chest computed tomography (CT) can be used to
diagnose other medical complications such as influenza A and B (A.D.A.M. Medical
Encyclopedia, 2011). The CDC created two algorithms for health professionals to follow in
order to diagnose and treat persons suspected to have SARS in 2003 (See Appendix A and B).
During the outbreak, the CDC based diagnoses on clinical symptoms, defined cases of
pneumonia, and contact with others infected with SARS as well as non-diagnostic elevated lab
values that were associated in other cases of confirmed SARS: lymphopenia with normal or low
white blood cell count, elevated hepatic transaminases, elevated creatine phosphokinase,
elevated lactate dehydrogenase, elevated C-reactive protein, and prolonged activated partial
thromboplastin time (CDC, 2005).
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Transmission
Transmission of SARS is thought to occur primarily through close interactions and
contact with persons who are infected. The main route of transmission is through respiratory
secretions (CDC, 2004). Additionally, transmission may occur through fecal/oral contact such as
direct contact with infected stool (CDC, 2005). Transmission may occur through direct and
indirect touch and can be transmitted through respiratory droplets. According to the CDC in
2005, true airborne transmission such as droplet nuclei could not be ruled out as a method of
transmission.
Personal Protective Equipment
Due to the methods of possible transmission of SARS, personal protection equipment
(PPE) should be utilized in hospital settings for all persons who present with symptoms of
SARS. Hand hygiene is the single most important step in prevention of any bacteria or virus
(CDC, 2005). Standard precautions should always take place in health care settings such as
donning gloves and washing in and out of patient rooms. Furthermore, for cases thought to
possibly be infected with SARS contact, droplet, and airborne PPEs should be utilized. Isolation
gowns and non-sterile gloves should be used by health professionals when entering the patient’s
room. A NIOSH-certified N-95 filtering mask should be utilized when entering the room as well
(CDC, 2005). Fit tests are required by the Occupational Safety and Health Administration
(OSHA) to ensure proper sealing takes place on the wearer’s face (OSHA, 2010). The CDC
recommends that all health professionals wear protective eye equipment when coming within
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three feet of any suspected infected person with SARS although no evidence has been found to
support the need for protective eyewear (CDC, 2005).
Isolation
Persons thought to be infected with SARS should be placed on isolation precautions in
hospital settings as well as within the community. For those persons thought to be infected in
medical settings, contact, droplet, and airborne isolation should take place (CDC, 2005). In 2003
persons in the community who were thought to be infected as well as those thought to come into
contact with infected persons was placed on isolation by staying within their homes (Bell, 2004).
According to David M. Bell, part of the WHO, quarantining persons who are infected are the
most acceptable and effective method of containing SARS (2004). The SARS epidemic led to
the cancellation of mass gatherings including schools and public facilities. In the event of future
outbreak of SARS, isolation should take place in order to decrease the number of potentially
infected persons as well as fatalities.
Therapy
Therapy for the treatment of SARS has been widely discussed and researched since the
outbreak in 2003. The Department of Microbiology and Immunology at the University of Texas
attempted to create and test a VLP vaccine for the treatment of SARS in mice and ferrets (Tseng,
Sbrana, Iwata-Yoshikawa, Newman, Garron, Atmar, Peters, & Couch, 2012). The findings of
the testing performed suggested that antibodies were produced in order to protect and fight
infection associated with SARS (Tseng, 2012). However, there was a Th2-type
immunopathology that occurred in the mice that suggested hypersensitivity to SARS-CoV
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components and a caution was set in place for the vaccine for all humans (Tseng, 2012). There
is no vaccine available at this time that is safe in the treatment of SARS (Tseng, 2012).
High dose steroids have been used in cases of SARS and have been proven to be
beneficial for symptoms and complications associated with SARS. Steroids help to reduce
swelling in the lungs that occurs with SARS (A.D.A.M Medical Encyclopedia, 2011).
Furthermore, high dose steroids may be used to treat large joint arthralgia, osteonecrosis, and
reduced bone mass (Griffith, 2011). There is no evidence that supports the effectiveness of
antivirals as treatment of SARS (CDC, 2005). However, oxygen therapy including mechanical
ventilation and chest therapy may be useful in treating the symptoms of SARS (A.D.A.M
Medical Encyclopedia, 2011).
Analysis of Evidence
The SARS epidemic lasted for just over a year and no further diagnoses have taken place
since that time. The WHO and CDC provided very clear recommendations for medical
personnel as well as for the public on the signs/symptoms of SARS and how to contain this
syndrome. The evidence suggests that containment of SARS and early diagnosis are essential in
preventing the spread of SARS. Contact, droplet, and airborne precautions should be enforced in
healthcare settings in which persons present with symptoms of SARS and have been in contact
with someone who had SARS in the past (CDC, 2005). PPEs should be implemented as well if
persons present with these symptoms especially in persons who travel or have been previously
infected with SARS (CDC, 2005). Although there have not been any confirmed cases of SARS
in recent years the CDC warns that re-introduction of SARS is possible and healthcare workers
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should be cautious when dealing with persons that may have been infected with SARS or been in
contact with someone with SARS (2005).
In the event of future outbreak of SARS the algorithms and guidelines set forth by the
CDC should be implemented. Testing should take place in persons presenting with respiratory
symptoms as well as fever, diarrhea, and headache. If a person is found to have pneumonia
testing should be performed in order to diagnose SARS. Diagnostic tests should be performed
including “complete blood count (CBC) with differential, chest radiography, pulse oximetry,
blood cultures, Sputum Gram's stain and culture testing for viral respiratory pathogens, notably
influenza A and B and respiratory syncytial virus, and legionella and pneumococcal urinary
antigen testing if radiographic evidence of pneumonia (adults only)” (CDC, 2005, Clinical
Work-Up).
Factors and Situations That May Promote SARS
SARS is thought to be of zoonotic origin—passing from infected animals to humans.
Although SARS has not been confirmed in humans since the pandemic there is a risk of future
outbreak. If persons are infected in the future it is possible that another pandemic may take place
if early containment and isolation does not occur. Persons or groups of persons in specific
demographic areas should be contained and tested for SARS when presenting with symptoms
associated with SARS. However, the presenting symptoms of SARS are very similar to a
common viral cold which may hinder early detection. Health care workers should be informed
of potential outbreaks and in the event that illness takes place in a large number of people in one
demographic location testing should take place to rule out SARS.
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In the event that an outbreak occurs it is essential for medical personnel to take special
precautions set forth by the CDC and quarantine those infected. Government agencies should be
notified and large gatherings in questionable demographic locations should be cancelled. Travel
to other demographic locations among persons with SARS or those in contact with others in
question with having SARS should not take place. Travel advisories should be implemented and
persons who are traveling should be evaluated prior to leaving the area. Because early symptoms
of SARS are similar to a common cold the spread of SARS may take place before quarantining
takes place. The pandemic in 2003 was spread from China to many other locations by
individuals who traveled as part of their profession. It is important that future outbreaks be
diagnosed early on. By containing those infected or in contact with infected persons and
following the algorithms set forth by the CDC another pandemic could be avoided.
Conclusion
The SARS pandemic that was first diagnosed China spread to over 29 countries in the
world and took the lives of many people. This virus caused multiple cold-like symptoms such as
difficulty breathing, rhinorrhea, fever, headache, muscle aches, and sore throat. The high
mortality rate for SARS during the pandemic is proof that early intervention, isolation, and
treatment of SARS are necessary in the future. However, the symptoms associated with SARS
may be overlooked as common viral infections. Therefore, it is important for healthcare workers
to be aware of the possibility of a SARS outbreak in the future and be prepared to take
appropriate methods in case of such an event. Although there is no vaccine available at this time
to prevent SARS, common medical practices such as good hand washing and standard universal
precautions may help prevent the spread of SARS. Additionally, contact, droplet, and airborne
isolation precautions should be initiated when a large number of people present with symptoms
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of SARS. By educating healthcare workers and the public another pandemic of SARS can be
avoided.
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References
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Appendix A
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Appendix B
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