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By: Swarali S Tadwalkar

PHC 6002: Infectious Disease Epidemiology
Instructor: Dr Aurora Sanchez-Anguiano
Image source: http://www.healthytravelblog.com/2012/09/25/the-return-of-sars/
http://bloomberg.nursing.utoronto.ca/news/teaching-in-a-time-of-crisis-sars-and-the-impact-on-u-of-ts-faculty-of-nursing
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* Viral Respiratory Disease caused by SARS-CoV (SARS
Coronavirus)
* Highly contagious atypical pneumonia
* First reported in February 2003 in Asia through a major
outbreak
* Importance:
* CDC declared SARS-CoV as a select agent in 2012 meaning it has
the potential to pose severe threat to public health and safety
* High transmissibility
* First important infectious disease of the new millenium
* Infection to HCW – Major concern
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* Etiologic Agent: SARS Coronavirus (SARS-CoV)
* Transmission: Primarily through droplet infection
* Other sources: Surface contamination and Air-borne
* Natural History: Acute viral infection of respiratory tract
* Viral dynamics not clear though high viral load seen in lower
respiratory tract
* Low load in upper respiratory tract and feces in the first 4
days but peaks at approximately 10 days
* High infectivity at febrile stage
* Life-cycle: RNA virus of coronaviridae family
* Important stages: Replication and Transcription
* Replication involves synthesis of full-length negative strand
* Discontinuous Transcription process not fully understood
Image source: https://socioecohistory.wordpress.com/2012/09/27/new-sars-virus-attacks-arabs-created-by-israeli-and-british-bio-weapons-lab/
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* Pathophysiology: Complex processes leading to degradation of organs
* Primary target - lungs and intestines (epithelial cells, villi, alveoli)
* Immune system - severe lymphocyte depletion
* Clinical Features: Incubation period is 2-10 days
* Fever, Myalgia, headaches, dry non-productive cough
* Others: Diarrhea (25%), shortness of breath, hypoxemia
* Diagnosis: Chest radiography, pulse oximetry, blood cultures, sputum
Gram stain and culture, and testing for other respiratory pathogens
* Treatment: Supportive care, infection control measures and broad
spectrum antibiotics including fluoroquinolone and macrolide
* Complications: Risk of co-infections, comorbities, respiratory failure
* Prognosis: Can lead to serious medical complications
* May require hospitalization, Intubation or ventilator support
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* Primary Reservoir = Human
* Other animal reservoirs for coronaviridae family viruses include cats,
pigs, chicken, rats and mice
* Infections include respiratory or enteric manifestations
* Person
* Total deaths = 774 out of 8,098 affected as per WHO
* Canada: Median reported age of death was 75 years
* Peoples’ Republic of China: 71.9% deaths were above 60 years of age
* HongKong, China: 52% deaths were amongst above 65 years olds
* Sex preference: Some studies report higher female CFR while some
report vice versa
* Racial preference has not been documented though outbreak was
restricted to about two dozen countries alone
* Greater transmission and infectivity was seen among Health care
workers perhaps due to exposure to higher viral load
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* Major outbreak in 2003
* No outbreak of SARS seen after that though other forms
such as MERS (Middle East Respiratory Syndrome) seen
* Time: No seasonal pattern
* Total incubation period: 1-14 days
* Median incubation period: 4-5 days with mean of 4-6 days
* Epidemic curve
* Person-to-person propagation
* Peaks of different heights
* Onset of outbreak: Nov 2002
* Global alert: March 15, 2003,WHO

Adapted from World Health Organization. Epidemic curves – Severe Acute Respiratory Disease (SARS)
http://www.who.int/csr/sars/epicurve/epiindex/en/index1.html
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* Place: About couple of dozen countries were affected
* Most cases occurred in:
* China
* Phillippines
* Vietnam
* Singapore
* Canada
* USA
* Some parts of Europe
* Only 8 cases were seen in US of which almost all had
travelled to other parts of the world

Image Source: Boulos International Journal of Health Geographics 2004 3:2 doi:10.1186/1476-072X-3-2
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* Intrinsic factors:
* Genetically, HLA (Human Leukocyte Antigen) was identified to
be correlated to SARS susceptibility
* Age of the patient: Higher incidence was seen amongst older
age group (> 60 years)
* Sex of the patient: Males were more likely to be affected
however, amongst HCWs more females were affected
* Children and pregnant women were considered to be at higher
risk
* Higher mortality was seen amongst patients with comorbidities
such as diabetes, heart diseases etc
* Variation in host response to infection
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* Extrinsic Factors
* Pathogenic virus: SARS Coronavirus
* Person-to-person contact: Droplet and Air transmission
* Led to higher transmittance to HCWs and spread of disease to
others in population
* Air travel: Led to spread of disease from China to Canada due
to travel of infected patients/carriers
* Lack of infection control measures leading to higher
transmission in health care settings
* Lack of maintenance of hygienic conditions
* Influence of diet or other lifestyle factors were not identified as
major risk factors during the outbreak. However, they may
have caused variability in susceptibility and immune response
of host
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* Concern: Insufficiency of vaccine due to new strain
* Global Alert issued by WHO in March 2003
* Monitoring passengers and crew traveling by air
* Quarantine of infected patients
* Avoiding mass gatherings and activities
* Infection control measures
* Preventing person-to-person contact (using masks)
* Handwashing
* Safety precautions by HCWs in healthcare settings
* Extra precaution during intubation and intensive care to avoid
exposure to high viral loads
* Surveillance and timely reporting
* Monitoring fever and cough symptoms amongst children and
adults every few hours in schools, offices and other institutions
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* Study by Raboud et. Al (2010)
* One of the most extensive epidemiological studies in health-care
settings in Ontario, Canada
* Merits: Detailed inclusion/exclusion criteria, extensive statistical
analysis
* Demerits: Retrospective nature may have led to recall bias in the
study, biological variability may have been a source of
confounding
* Donnely et. al (2003)
* Assessed epidemiology of SARS in Hong Kong, China
* Result: Patient’s age was strongly associated with outcome
* Merits: Detailed study design and methods, inclusion/exclusion
criteria, large sample-size
* Demerits: Non-stratification by sex, less information on other
factors and self-reporting of information
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* Other coronavirus disease forms witnessed: MERS (Middle
East Respiratory Syndrome)
* Concern over mutant forms of viral strains making it
difficult to determine diagnosis and treatment
* During 2003 SARS outbreak, treatment could not be easily
determined making it difficult to treat patients and preventing
spread
* Protective efficacy of vaccines still under scrutiny
* Research with novel ideas to manage diseases required
* DNA vaccine could potentially prevent proliferation of RNA
virus by hindering replication
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* CDC/NCIRD. (2004). Basic Information about SARS. CDC/NCIRD.
* Chan, H. L., Tsui, S. K., & Sung, J. J. (2003). Coronavirus in severe acute
respiratory syndrome (SARS). TRENDS in Molecular Medicine, 9: 323-325.
* Donnelly, C. A., Ghani, A. C., Leung, G. M., Hedley, A. J., Fraser, C., Riley, S.,
et al. (2003). Epidemiological determinants of spread of causal agent of severe
acute respiratory syndrome in Hong Kong. The Lancet, 1-6.
* Gu, J., & Korteweg, C. (2007). Pathology and Pathogenesis of Severe Acute
Respiratory Syndrome. The American Journal of Pathology, 170:1136–1147; DOI:
10.2353/ajpath.2007.061088.
* Ng, M., Cheng, S., Lau, K., Leung, G., Khoo, U., Zee, B., et al. (2010).
Immunogenetics in SARS: a case control study. Hong Kong Medical Journal,
16(Suppl 4):S29-33.
* Raboud J, Shigayeva A, McGeer A, Bontovics E, Chapman M, et al. (2010) Risk
Factors for SARS Transmission from Patients Requiring Intubation: A
Multicentre Investigation in Toronto, Canada. PLoS ONE 5(5): e10717.
doi:10.1371/journal.pone.0010717
* Sampathkumar, P., Temesgen, Z., Smith, T. F., & Thompson, R. L. (2003).
SARS: Epidemiology, Clinical Presentation, Management, and Infection
Control Measures. Mayo Clinic Proceedings, 78:882-890.
* SARS Epidemiology Working Group, W. (2003). Consensus Document on the
Epidemiology of SARS. WHO.
*Any questions??