Severe Acute Respiratory Syndrome (SARS)

Severe Acute Respiratory
Syndrome (SARS), Middle East

Respiratory Syndrome (MERS)
DR. BISHAL
SARS is an acute viral respiratory illness.
It is caused by Coronavirus called SARS-
associated coronavirus (SARS-CoV).
The first case was reported in a health worker
in China in November 2002 followed by an
epidemic which spread to Hong Kong,
Singapore, Vietnam, Taiwan and Toronto and
later to other countries.
Over 8,000 known cases reported in eight
months in 26 countries among which 774 died.
Problem statement
21% affected were healthcare workers

The most recent human cases were reported
in China in April 2004 in an outbreak
resulting from laboratory-acquired infections.
Currently, there is no known SARS
transmission anywhere in the world.
Epidemiological factors
Agent: single stranded, RNA virus of Corona

virus family
The virus can survive for hours on common
surfaces outside human body and up to 4
days in respiratory secretions and stool.
The virus can survive for at least 24 hours on
a plastic surface at room temperature and
can live for extended periods in the cold
weather.
Reservoir: human reservoir; bats potential
reservoir
Age incidence: common among people above
25 years of age.
Sex incidence: common among men
Transmission: primarily human to human
Mode of transmission
Others
Use of aerosol generating techniques may
amplify the transmission of virus
(nebulization, endotracheal intubation etc.)
The virus is shed in stool but role of fecal-oral
transmission is not known.
Infectious material: nasal and throat
secretions
Incubation period: 2 to 10 days
Symptoms of SARS
May be mild to severe

Influenza like symptoms
Most frequently associated with fever and rigor
Other symptoms may include headache, feeling of
discomfort and body aches and diarrhoea.
Some people also have mild respiratory symptoms
at the onset like cough, shortness of breath etc.
Most patients develop pneumonia in 7-10 days of
illness.
There may be rapid deterioration with progressive
hypoxemia requiring ventilatory support.
WHO definition of a Suspected Case
A person with a documented fever

(temperature >38 °C)
Lower respiratory tract symptoms,
Contact with a person believed to have had
SARS
Or a history of travel to a geographic area
where there has been documented
transmission of the illness.
Probable case
A suspected case with

1) chest radiographic findings of pneumonia,
or
2) acute respiratory distress syndrome, or
3) an unexplained respiratory illness resulting
in death with autopsy findings consistent
with the pathology of ARDS without an
identifiable cause
Lab investigations
Chest radiograph
Pulse oximetry
Complete blood count
Tests for other possible causes
SARS-CoV testing should be considered if no
alternative diagnosis is identified 72 hours
after initiation of the clinical evaluation and
the patient is thought to be at high risk for
SARS-CoV disease.
Confirmatory diagnostic tests
PCR
ELISA
Virus isolation
In the absence of known SARS-CoV
transmission to humans, the diagnosis should
be independently verified in one or more
WHO labs.
Every single case must be reported to the
WHO.
Specimen that can be used for
diagnosis
1) nasopharyngeal wash/aspirates,
2) nasopharyngeal swabs,
3) oropharyngeal swabs,
4) broncheoalveolar lavage,
5) tracheal aspirate,
6) pleural fluid tap,
7) sputum;
8) post-mortem tissue
Risk factors
Close contacts
Health workers involved in procedures
generating aerosols
Exposure on 2nd week of illness or severely ill
case or rapidly deteriorating case
Close contact
Close contact means having cared for or lived

with someone with SARS or having direct
contact with respiratory secretions or body
fluids of a patient with SARS.
Examples include kissing or hugging, sharing
of eating or drinking utensils, talking to
someone within 3 feet, and touching someone
directly.
Close contact does not include activities like
walking by a person or briefly sitting across a
waiting room or office.
Complications
Acute respiratory distress syndrome (16%)

Secondary bacterial infection
Tension pneumothorax
Non-cardiogenic pulmonary edema
Treatment
Intensive support
Antiviral agents like Ribavirin,
lopinavir/ritonavir, interferon 1, IV
immunoglobulin, systemic corticosteroid
Prognosis
Overall mortality rate is 14%.

Poor prognosis in
- advanced age,
- chronic infection like Hepatitis B, diabetes
mellitus etc.
- high initial or high peak lactate
dehydrogenase concentration,
- high neutrophil count on presentation,
- acute kidney disease
- low counts of CD4 and CD8 on presentation
Prevention and control
Prompt identification of cases and contacts

Effective isolation of cases in hospitals
Appropriate protection of medical staff
treating these cases: use of goggles, mask,
gloves etc.
Exit screening of international travelers.
Timely and accurate reporting and sharing of
information with other authorities and/or
governments
Other preventive measures
Cover mouth and nose while sneezing or

coughing.
Use tissues to contain respiratory secretions
and dispose properly.
Do not share food, drink, or utensils.
Clean commonly touched surfaces with
disinfectant.
Hand washing
Middle East respiratory syndrome
coronavirus (MERS-CoV)
It is a viral respiratory disease caused by

coronavirus (Middle East respiratory syndrome
coronavirus, or MERS‐CoV) that was first
identified in Saudi Arabia in 2012.
Common symptoms include fever, cough and
shortness of breath.
Pneumonia is common, but not always present.
Gastrointestinal symptoms, including
diarrhoea, have also been reported.
Any age group can be affected.
Some laboratory-confirmed cases of MERS-
CoV infection are reported as asymptomatic.
Case fatality is 35%.
Camels are assumed to be major reservoir
and source of infection for MERS-CoV.
High risk group
People with diabetes, cancer, and chronic

lung, heart, and kidney disease.
Individuals with weakened immune systems
Mode of transmission
Animals to human
Human to human
Since 2012, 27 countries have reported cases of
MERS including countries from Arab league
(Algeria, Bahrain, Egypt, Jordan, Kuwait,
Lebanon, Oman, Qatar,, Kingdom of Saudi Arabia,
Tunisia, United Arab Emirates and Yemen. Other
reported cases are from Austria, China, France,
Germany, Greece, Iran, Italy, Malaysia, the
Netherlands, Philippines, Republic of Korea,
Thailand, Turkey, United Kingdom and United
States.
Approximately 80% of human cases have been
reported by Saudi Arabia.
Between 6 and 13 December 2016 the Focal
Point of Saudi Arabia reported ten additional
cases of Middle East Respiratory Syndrome
(MERS) including two fatal cases. Three
deaths among previously reported MERS
cases were also reported.
Confirmed case
A person with lab confirmation of MERS-CoV

infection irrespective of clinical signs and
symptoms.
Probable case
1. An acute febrile respiratory illness with

clinical, radiological or histopathological
evidence of pneumonia or ARDS
AND direct epidemiological link with lab
confirmed case
AND test unavailable, negative on single
inadequate specimen or inconclusive
2. An acute febrile respiratory illness with
clinical, radiological or histopathological
evidence of pneumonia or ARDS that can’t be
fully explained by any other etiology
AND person resides or travelled in Middle East
or countries where MERS CoV is known to be
circulating in dromedary camels or where
human infection have recently occurred
AND testing is inconclusive
3. An acute febrile respiratory illness of any
severity
AND direct epidemiological link with confirmed
case
AND test inconclusive
CDC recommends collecting multiple
specimens:
- bronchoalveolar lavage
- sputum and tracheal aspirates
- nasopharyngeal and oropharyngeal swabs
- serum
- stool
Investigations
Real-time reverse-transcription polymerase

chain reaction (rRT-PCR)
Serology:
 ELISA for screening
 IFA (immunofluorescence assay) for
confirmation
 Microneutralization assay for confirmation
Prevention and control
No vaccine or specific treatment is currently available.

Treatment is supportive and based on the patient’s
clinical condition.
Anyone visiting farms, markets or other places where
dromedary camels and other animals are present
should practice general hygiene measures, including
regular hand washing before and after touching
animals, and should avoid contact with sick animals.
Animal products like milk, meat etc. should be used
with care.
Infection prevention and control measures in health
facilities.
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Severe Acute Respiratory Syndrome (SARS)

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Severe Acute Respiratory

Syndrome (SARS), Middle East

21% affected were healthcare workers

Agent: single stranded, RNA virus of Corona

May be mild to severe

A person with a documented fever

A suspected case with

Close contact means having cared for or lived

Acute respiratory distress syndrome (16%)

Overall mortality rate is 14%.

Prompt identification of cases and contacts

Cover mouth and nose while sneezing or

It is a viral respiratory disease caused by

People with diabetes, cancer, and chronic

A person with lab confirmation of MERS-CoV

1. An acute febrile respiratory illness with

Real-time reverse-transcription polymerase

No vaccine or specific treatment is currently available.

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